Case-Informed Learning in Medical Education: A Call for Ontological Fidelity.

Case-informed learning is an umbrella term we use to classify pedagogical approaches that use text-based cases for learning. Examples include Problem-Based, Case-Based, and Team-Based approaches, amongst others. We contend that the cases at the heart of case-informed learning are philosophical artefacts that reveal traditional positivist orientations of medical education and medicine, more broadly, through their centering scientific knowledge and objective fact. This positivist orientation, however, leads to an absence of the human experience of medicine in most cases. One of the rationales for using cases is that they allow for learning in context, representing aspects of real-life medical practice in controlled environments. Cases are, therefore, a form of simulation. Yet issues of fidelity, widely discussed in the broader simulation literature, have yet to enter discussions of case-informed learning. We propose the concept of ontological fidelity as a way to approach ontological questions (i.e., questions regarding what we assume to be real), so that they might centre narrative and experiential elements of medicine. Ontological fidelity can help medical educators grapple with what information should be included in a case by encouraging an exploration of the philosophical questions: What is real? Which (and whose) reality do we want to simulate through cases? What are the essential elements of a case that make it feel real? What is the clinical story we want to reproduce in case format? In this Eye-Opener, we explore what it would mean to create cases from a position of ontological fidelity and provide suggestions for how to do this in everyday medical education.

Seven ways to get a grip on running a successful promotions process.

Promotion within an academic institution is often a key component of a career; however, there are often barriers to successful applications. A streamlined and transparent process can assist faculty members in their goals of obtaining promotion, leading to greater security and satisfaction. This paper describes a methodology designed at a local level to maximize opportunities for success, in the hope that others may learn from the experience and advocate for similar changes within their own institutions.

La promotion dans une établissement universitaire est souvent un élément clé dans la carrière. Or, les candidats se heurtent à bien des obstacles. Un processus simplifié et transparent peut aider les membres du corps professoral à atteindre leurs objectifs de promotion et leur apporter davantage de sécurité et de satisfaction. Cet article décrit la méthodologie que nous avons conçue localement pour maximiser les chances de réussite, dans l'espoir que notre expérience puisse être utile à d'autres enseignants qui souhaiteraient prôner des changements similaires au sein de leur établissement.

CAEP 2016 Academic Symposium on Education Scholarship: Training our Future Clinician Educators in Emergency Medicine.

OBJECTIVE: To develop consensus recommendations for training future clinician educators (CEs) in emergency medicine (EM). METHODS: A panel of EM education leaders was assembled from across Canada and met regularly by teleconference over the course of 1 year. Recommendations for CE training were drafted based on the panel's experience, a literature review, and a survey of current and past EM education leaders in Canada. Feedback was sought from attendees at the Canadian Association of Emergency Physicians (CAEP) annual academic symposium. Recommendations were distributed to the society's Academic Section for further feedback and updated by a consensus of the expert panel. RESULTS: Recommendations were categorized for one of three audiences: 1) Future CEs; 2) Academic departments and divisions (AD&D) that support training to fulfill their education leadership goals; and 3) The CAEP Academic Section. Advanced medical education training is recommended for any emergency physician or resident who pursues an education leadership role. Individuals should seek out mentorship in making decisions about career opportunities and training options. AD&D should regularly perform a needs assessment of their future CE needs and identify and encourage potential individuals who fulfill education leadership roles. AD&D should develop training opportunities at their institution, provide support to complete this training, and advocate for the recognition of education scholarship in their institutional promotions process. The CAEP Academic Section should support mentorship of future CEs on a national scale. CONCLUSION: These recommendations serve as a framework for training and supporting the next generation of Canadian EM medical educators.

An Environmental Scan of Academic Emergency Medicine at the 17 Canadian Medical Schools: Why Does this Matter to Emergency Physicians?

OBJECTIVE: We sought to conduct a major objective of the CAEP Academic Section, an environmental scan of the academic emergency medicine programs across the 17 Canadian medical schools. METHODS: We developed an 84-question questionnaire, which was distributed to academic heads. The responses were validated by phone by the lead author to ensure that the questions were answered completely and consistently. Details of pediatric emergency medicine units were excluded from the scan. RESULTS: At eight of 17 universities, emergency medicine has full departmental status and at two it has no official academic status. Canadian academic emergency medicine is practiced at 46 major teaching hospitals and 13 specialized pediatric hospitals. Another 69 Canadian hospital EDs regularly take clinical clerks and emergency medicine residents. There are 31 full professors of emergency medicine in Canada. Teaching programs are strong with clerkships offered at 16/17 universities, CCFP(EM) programs at 17/17, and RCPSC residency programs at 14/17. Fourteen sites have at least one physician with a Master's degree in education. There are 55 clinical researchers with salary support at 13 universities. Sixteen sites have published peer-reviewed papers in the past five years, ranging from four to 235 per site. Annual budgets range from $200,000 to $5,900,000. CONCLUSION: This comprehensive review of academic activities in emergency medicine across Canada identifies areas of strengths as well as opportunities for improvement. CAEP and the Academic Section hope we can ultimately improve ED patient care by sharing best academic practices and becoming better teachers, educators, and researchers.

Understanding the Experience of Miscarriage in the Emergency Department.

INTRODUCTION: Up to 20% of pregnancies end in miscarriage, which can be a significant life event for women with psychological implications. Because the only preventative measure for a miscarriage is risk factor modification, the treatment focuses on confirming the miscarriage has occurred and medical management of symptoms. Although women experiencing a miscarriage are frequently directed to seek medical care in emergency departments, the patients are often triaged as nonemergent patients unless they are unstable, which exposes women to potentially prolonged wait times. Research about miscarriages and emergency departments predominantly focus on medical management with little understanding of how emergency care shapes the experience of miscarriage for women. METHODS: Seeking to describe the experiences of women coming to the emergency department for care while having a miscarriage, interpretive phenomenology-a form of qualitative research-guided this study. Eight women were recruited to participate in semi-structured face-to-face interviews of 60 to 90 minutes in length. Data were analyzed using hermeneutics and thematic analysis. RESULTS: Five themes emerged: "Pregnant/Life: Miscarriage/Death"; "Deciding to go to the emergency department: Something's wrong"; "Not an illness: A different kind of trauma"; "Need for acknowledgement"; and "Leaving the emergency department: What now?". Participants believed their losses were not acknowledged but instead dismissed. These experiences, combined with a perceived lack of discharge education and clarity regarding follow-up, created experiences of marginalization. DISCUSSION: This study describes the experience of miscarrying in emergency departments and provides insights regarding how nursing and physician care may affect patient perceptions of marginalization.

Experiences of emergency department nurses in providing palliative care to adults with advanced cancer: a systematic review protocol.

REVIEW QUESTIONS/OBJECTIVES: The objective of this review is to explore the experiences and perceptions of emergency department nurses in providing palliative care to adults with advanced cancer so as to contribute to the developing knowledge base on this phenomenon and, in turn, inform future practice and policy changes. Specifically, the review question for this qualitative review is as follows: what are the experiences and perceptions of emergency department nurses in providing palliative care to adults with advanced cancer?

Delayed pericardial effusion and cardiac tamponade following penetrating chest trauma.

We present the case of a 20-year-old man who was stabbed in the left chest and was diagnosed with a large pericardial effusion by focused emergency department (ED) ultrasonography. After placement of a left chest tube for presumed tension pneumothorax, the pericardial effusion had resolved. The patient's postinjury course was complicated by pericarditis and recurrent tamponade, which required repeated pericardiocentesis for management. This case illustrates the role of focused ED ultrasonography for diagnosis of pericardial effusion in penetrating trauma and the potential for delayed pericardial effusion and tamponade in such patients. Although the pathophysiology of delayed pericardial effusion is unclear, autoimmune postpericardiotomy syndrome has been proposed as the cause of this rare condition. Our case underscores the importance of close monitoring of patients with known or suspected pericardial injuries due to their potential for the development of life-threatening complications.

Can the introduction of an integrated service model to an existing comprehensive palliative care service impact emergency department visits among enrolled patients?

PURPOSE: Fewer emergency department (ED) visits may be a potential indicator of quality of care during the end of life. Receipt of palliative care, such as that offered by the adult Palliative Care Service (PCS) in Halifax, Nova Scotia, is associated with reduced ED visits. In June 2004, an integrated service model was introduced into the Halifax PCS with the objective of improving outcomes and enhancing care provider coordination and communication. The purpose of this study was to explore temporal trends in ED visits among PCS patients before and after integrated service model implementation. METHODS: PCS and ED visit data were utilized in this secondary data analysis. Subjects included all adult patients enrolled in the Halifax PCS between January 1, 1999 and December 31, 2005, who had died during this period (N = 3221). Temporal trends in ED utilization were evaluated dichotomously as preintegration or postintegration of the new service model and across 6-month time blocks. Adjustments for patient characteristics were performed using multivariate logistic regression. RESULTS: Fewer patients (29%) made at least one ED visit postintegration compared to the preintegration time period (36%, p < 0.001). Following adjustments, PCS patients enrolled postintegration were 20% less likely to have made at least one ED visit than those enrolled preintegration (adjusted OR 0.8; 95% confidence interval 0.6-1.0). CONCLUSION: There is some evidence to suggest the introduction of the integrated service model has resulted in a decline in ED visits among PCS patients. Further research is needed to evaluate whether the observed reduction persists.

Palliative care patients in the emergency department.

Although end-of-life care is not a primary function of the emergency department (ED), in reality, many access this department in the later stages of illness. In this study, ED use by patients registered with the Capital Health Integrated Palliative Care Service (CHIPCS) is examined and CHIPCS patient characteristics associated with ED use identified. Overall, 27% of patients made at least one ED visit while registered with CHIPCS; 54% of these resulted in a hospital admission. ED visiting was not associated with time of day or day of the week. Multivariate logistic regression results suggest older patients were significantly less likely to make an ED visit. Making an ED visit was associated with hospital death, rural residence (particularly for women), and having a parent or relative other than a spouse or child as the primary caregiver. Further research may suggest strategies to reduce unnecessary ED visits during the end of life.

Functional conservation of Rel binding sites in drosophilid genomes.

Evolutionary constraints on gene regulatory elements are poorly understood: Little is known about how the strength of transcription factor binding correlates with DNA sequence conservation, and whether transcription factor binding sites can evolve rapidly while retaining their function. Here we use the model of the NFKB/Rel-dependent gene regulation in divergent Drosophila species to examine the hypothesis that the functional properties of authentic transcription factor binding sites are under stronger evolutionary constraints than the genomic background. Using molecular modeling we compare tertiary structures of the Drosophila Rel family proteins Dorsal, Dif, and Relish and demonstrate that their DNA-binding and protein dimerization domains undergo distinct rates of evolution. The accumulated amino acid changes, however, are unlikely to affect DNA sequence recognition and affinity. We employ our recently developed microarray-based experimental platform and principal coordinates statistical analysis to quantitatively and systematically profile DNA binding affinities of three Drosophila Rel proteins to 10,368 variants of the NFKB recognition sequences. We then correlate the evolutionary divergence of gene regulatory regions with differences in DNA binding affinities. Genome-wide analyses reveal a significant increase in the number of conserved Rel binding sites in promoters of developmental and immune genes. Significantly, the affinity of Rel proteins to these sites was higher than to less conserved sites and was maintained by the conservation of the DNA binding site sequence (static conservation) or in some cases despite significantly diverged sequences (dynamic conservation). We discuss how two types of conservation may contribute to the stabilization and optimization of a functional gene regulatory code in evolution.

Accuracy and reproducibility of protein-DNA microarray technology.

Microarray-based methods for understanding protein-DNA interactions have been developed in the last 6 years due to the need to introduce high-throughput technologies in this field. Protein-DNA microarrays utilise chips upon which a large number of DNA sequences may be printed or synthesised. Any DNA-binding protein may then be interrogated by applying either purified sample or cellular/nuclear extracts, subject to availability of a suitable detection system. Protein is simply added to the microarray slide surface, which is then washed and subjected to at least one further incubation with a labelled molecule which binds specifically to the protein of interest. The signal obtained is proportional to the level of DNA-binding protein bound to each DNA feature, enabling relative affinities to be calculated. Key factors for reproducible and accurate quantification of protein binding are: microarray surface chemistry; length of oligonucleotides; position of the binding site sequence; quality of the protein and antibodies; and hybridisation conditions.

Aspiration pneumonitis requiring intubation after procedural sedation and analgesia: a case report.

Emergency department (ED) procedural sedation and analgesia is widely and routinely performed; serious complications are rare. We describe the first reported case of aspiration during procedural sedation in the ED. Although our patient required endotracheal intubation and critical care admission, there was no adverse long-term outcome. Given that there were no apparent predisposing factors, we believe it is crucial for emergency physicians to routinely anticipate the possibility of such a complication during each sedation event.

Quantitative profiling of protein-DNA binding on microarrays.

Recent studies on genome-wide localization of transcription factor (TF) binding to DNA have shown that a large proportion of identified sequences do not contain consensus motifs predicted by databases of transcription factor binding sites, such as TRANSFAC. The main limitation of these databases is that they are based on a literature search of published examples of binding; consequently the data are not from a systematic survey and may be subject to sampling biases if investigators focused on particular motifs. Thus, there is an urgent need for systematic profiling of vertebrate transcription factor binding to DNA. We have developed a high-throughput platform for the quantitative analysis of protein-DNA interactions based on microarray technology.

Emergency department use by CTAS Levels IV and V patients.

INTRODUCTION: Many emergency department (ED) visits are non-urgent. Postulated reasons for these visits include lack of access to family physicians, convenience and 24/7 access, perceived need for investigations or treatment not available elsewhere, and as a mechanism for expedited referral to other specialists. We conducted a patient survey to determine why non-urgent patients use our tertiary care ED. Our primary objective was to determine how often the lack of a family physician was associated with non-urgent ED use. METHODS: The survey was administered to Canadian Emergency Department Triage and Acuity Scale (CTAS) Level IV and V patients who attended the ED of the Queen Elizabeth II Health Sciences Centre in Halifax, NS, from March 7 to March 13, 2005. RESULTS: Of the 352 eligible patients, 235 completed the survey (response rate, 67%). Fifty-six percent (132/235) had an acute medical problem of less than 48 hours, including 48% (114/235) with a recent injury. Thirty-four percent (82/235) had been referred to the ED, 49% (114/235) believed they required a specific service that was unavailable elsewhere (e.g., radiology, suturing, casting) and 43% (100/235) presented because of self-perceived urgency of their condition. Eighty-four percent (198/235) had a family physician; 23% (55/235) used the ED because of limited access to their family physician and 3% (6/235) used the ED because they did not have a family physician. CONCLUSIONS: In this setting, most non-urgent ED visits involved patients who required a specific service offered by the ED, patients who believed their condition was urgent, or patients who were referred from the community to the ED. From a patient perspective, relatively few visits would be considered inappropriate. Lack of a family physician was not associated with non-urgent ED use; however, inability to obtain timely access to the FP was a factor in one-quarter of cases.

Quantitative high-throughput analysis of transcription factor binding specificities.

We present a general high-throughput approach to accurately quantify DNA-protein interactions, which can facilitate the identification of functional genetic polymorphisms. The method tested here on two structurally distinct transcription factors (TFs), NF-kappaB and OCT-1, comprises three steps: (i) optimized selection of DNA variants to be tested experimentally, which we show is superior to selecting variants at random; (ii) a quantitative protein-DNA binding assay using microarray and surface plasmon resonance technologies; (iii) prediction of binding affinity for all DNA variants in the consensus space using a statistical model based on principal coordinates analysis. For the protein-DNA binding assay, we identified a polyacrylamide/ester glass activation chemistry which formed exclusive covalent bonds with 5'-amino-modified DNA duplexes and hindered non-specific electrostatic attachment of DNA. Full accessibility of the DNA duplexes attached to polyacrylamide-modified slides was confirmed by the high degree of data correlation with the electromobility shift assay (correlation coefficient 93%). This approach offers the potential for high-throughput determination of TF binding profiles and predicting the effects of single nucleotide polymorphisms on TF binding affinity. New DNA binding data for OCT-1 are presented.