Closing the gender pay gap in emergency medicine: Paradigms to consider for leaders, faculty, and trainees.

The gender pay gap among physicians is a well documented and persistent problem and has a profound impact on earnings over a career lifetime. This paper describes examples of concrete initiatives three institutions took to identify and address gender pay gaps. Salary audits at two academic emergency departments highlight the importance of not only ensuring equity in salary among physicians of the same rank but also monitoring whether women are achieving equal representation at higher academic ranks and leadership, elements that typically contribute to compensation. These audits reveal how senior rank and formal leadership roles are significantly associated with salary disparities. A third school of medicine-wide initiative entailed conducting comprehensive salary audits followed by review and adjustment of faculty compensation to achieve pay equity. Graduating residents and fellows seeking first jobs out of training and faculty looking to be compensated equitably would benefit from understanding the elements that drive their compensation and advocating for frameworks that are understandable and transparent.

Stroke care in Armenia: Recent developments.

Introduction: Armenia is an upper-middle-income country with a population of nearly 3 million. Stroke is one of its major public health problems and ranks as the sixth leading cause of death, with a mortality of 75.5 per 100,000. Methods and results: Until recently, modern stroke care was not available in Armenia. During the past 8 years substantial advances have been made in building medical infrastructure and delivering acute stroke care. This manuscript describes contributors to this progress, including extensive and long-term collaboration with international stroke experts, the development of hospital-based stroke teams, and a funding commitment for stroke care by the government. Conclusion: The results of acute stroke revascularization procedures during the past 3 years are reviewed and found to meet international standards. Future directions are discussed including the immediate need to expand acute stroke care to underserved parts of the country by adding primary and comprehensive stroke centers. An active educational program for nurses and physicians and the TeleStroke system development will help support this expansion.

Hybrid warfare and public health: Conflicts in Ukraine and Nagorno-Karabakh raise the alarm.

Hybrid warfare strategies include weaponization of healthcare, the use of non-conventional weapons, and strategic displacement of civilian populations via direct targeting, sexual violence, disinformation campaigns, and disruption of essential services such as water, food, gas, and access to health services. All these actions harm public health. The current war in Ukraine and the 2020 Second Nagorno-Karabakh war between Azerbaijan and Armenia serve as vivid examples of the novel and devastating public health effects of hybrid warfare targeting civilians. The lessons learned from these conflicts should serve as a warning and a call to action. Politicians and public health officials should advocate for a comprehensive rethinking of previous measures to counteract the impacts of hybrid warfare. Concerted efforts and strategies to mitigate these impacts on public health at every phase are essential. De-escalation of conflicts should be facilitated, and civilian health should be prioritized by the global community by instituting a more punitive and comprehensive schema to both deter war and step-up penalties for the tactics of hybrid warfare. Failure to do so will undoubtedly result in this scenario being played out with greater frequency globally, erasing the public health wins of the previous century.

Advanced practice providers in academic emergency medicine: A national survey of chairs and program directors.

BACKGROUND: The Society for Academic Emergency Medicine Board of Directors convened a task force to elucidate the current state of workforce, operational, and educational issues being faced by academic medical centers related to advanced practice providers (APPs). The task force surveyed academic emergency department (ED) chairs and residency program directors (PDs). METHODS: The survey was distributed to the Association of Academic Chairs of Emergency Medicine (AACEM)-member chairs and their respective residency PDs in 2021. We surveyed 125 chairs with their self-identified PDs. The survey sampled hiring, state-independent practice laws, scope of practice, teaching and supervision, training opportunities, delegation of procedures between physician learners and APPs, and perceptions of the impact on resident and medical student education. RESULTS: Of the AACEM-member chairs identified, 73% responded and 47% of PDs responded. Most (98%) employ either physician assistants or nurse practitioners. Among responding departments, 86% report APPs working in fast-track settings, 80% work in the main ED, and 54% work in the waiting room. In 44% of departments, APPs and residents evaluate patients concurrently, and 2% of respondents reported that APPs manage high-acuity patients without attending involvement. Two-thirds of chairs believe that APPs contribute positively to the quality of patient care, while 44% believe that APPs contribute to the academic environment. One-third of PDs believe that the presence of APPs interferes with resident education. Although 75% of PDs believe that residents require training to work effectively with APPs in the ED, almost half (49%) report zero hours of training around APP supervision or collaborative skills. CONCLUSIONS: APPs are ubiquitous across academic EDs. Future research is required for academic ED leaders to balance physician and APP deployment across the academic ED within the context of patient care, resident education, institutional resources, professional development opportunities for APP staff, and standardization of APP EM training.

Communication in the Time of COVID-19.

The ideal way to make a connection with patients and their families is well studied. Despite these prescriptive measures, communication in emergency medicine is never easy. This past year and a half with restrictions imposed by coronavirus, all levels of communication have been made more difficult. This humanities in medicine essay uses patient examples to illustrate the challenges and pitfalls encountered when family and friends are no longer able to participate in history taking.

National Awards and Female Emergency Physicians in the United States: Is the "Recognition Gap" Closing?

BACKGROUND: Gender inequities in recognition, compensation, promotion, and leadership roles exist in emergency medicine. Formal recognition in the workplace and opportunities for advancement are vulnerable to bias. OBJECTIVE: To examine the gender distribution of national awards in emergency medicine, to analyze whether there is a gap, and to highlight notable trends. METHODS: Recipients of the major award categories between 2001 and 2020 were examined for the 3 main national emergency medicine organizations. The gender distribution of award winners by year was compared with the gender distribution of female faculty in emergency medicine departments using data from the Association of American Medical Colleges and a chi-squared analysis. RESULTS: The gender gap in award winners has decreased over time, but men are still disproportionately given national awards over women. In all 3 organizations, women represented a smaller proportion of award winners than men when compared with the national proportion of women in academic emergency medicine. Advocacy awards were the one category where women were more likely to be recognized. Women were notably least likely to receive clinical and leadership awards. CONCLUSIONS: The gender gap in emergency medicine awards has narrowed in the last 20 years but still exists. This discrepancy is an example of how bias can compound over time to generate gaps in recognition, career advancement, and promotion. The pipeline to award nominations should be addressed at the individual, departmental, awards committee, and organizational levels. © 2021 Elsevier Inc.

Emergency care and the patient experience: Using sentiment analysis and topic modeling to understand the impact of the COVID-19 pandemic.

The COVID-19 pandemic has presented many unique challenges to patient care especially in emergency medicine. These challenges result in an altered patient experience. Patient experience refers to the cumulative impression made on patients during their medical visit and is measured by a standardized survey tool. Patient experience is considered a key measure of quality of care. The volume of survey data received makes it difficult to spot trends and concerns in patient comments. Topic modeling and sentiment analysis are well documented analytic techniques that can be used to gain insight into patient experience and make sense of vast quantities of data. This study examined three periods of time, pre, during and post-COVID-19 first wave in order to identify key trends in sentiment and topics related to patient experience. Previously collected, anonymized Press Ganey (PG) survey data was used from three northeastern emergency department that make up an academic emergency department. Data was collected for three contiguous time periods: Pre-COVID-19 (12/10/2019- 3/10/2020), During COVID-19: (3/11/2020-6/10/2020), and Post-first wave COVID-19 (6/11/2020- 9/10/2020). Preprocessing of the data was carried out then a sentiment label (i.e., positive, negative, neutral, mixed) was assigned by the tool. These labels were used to assess the validity of Press Ganey labels. Next, a topic modeling approach from machine learning was used to analyze the contents of the patient comments and uncover concerns and perceptions of patient experiences. Themes that emerged from the analysis of patient comments included concerns over personal safety and exposure to the virus, exclusion of family from decision making and care and high levels of scrutiny over systems issues, care, and treatment protocols. Topic modeling showed shifting priorities and concerns throughout the three periods examined. Prior to the pandemic, patient comments were largely positive and focused on technical expertise and perceptions of competence. New topics and concerns that patients reported relevant to the pandemic were identified during-COVID-19. Comments on systems issues regarding processes to limit viral spread and concerns over family/visitor restrictions were dominant. Although there was evidence of praise and appreciation of the efforts of staff there was also a high level of scrutiny of the processes encountered during the emergency visit. Sentiment analysis and topic modeling offer a unique method for organizing and analyzing the shifting concerns of patients and families. Suggestions of interventions are made to address these evolving concerns. The automation of analysis using artificial intelligence would allow for rapid and accurate analysis of patient feedback.

A Review of Interprofessional Variation in Education: Challenges and Considerations in the Growth of Advanced Practice Providers in Emergency Medicine.

The employment and utilization of advanced practice providers (APPs) in the emergency department has been steadily increasing. Physicians, physician assistants (PAs), and nurse practitioners (NPs) have vastly different requirements for admission to graduate programs, clinical exposure, and postgraduate training. It is important that as supervisory physicians, patients, hospital administrators, and lawmakers, we understand the differences to best create a collaborative, supportive, and educational framework within which PAs/NPs can work effectively as part of a care team. This paper reviews the trends, considerations, and challenges of an evolving clinician workforce in the specialty of emergency medicine (EM). Subsequently, the following parameters of APP training are examined and discussed: the divergence in physician, PA, and NP education and training; requirements of PA and NP degree programs; variation in clinical contact hours; degree-specific licensing and postgraduate EM certification; opportunities for specialty training; and the evolution and availability of residency programs for APPs. The descriptive review is followed by a discussion of contemporary and timely issues that impact EM and considerations brought forth by the expansion of APPs in EM such as the current drive to independent practice and the push for reimbursement parity. We review current position statements from pertinent professional organizations regarding PA and NP capabilities, responsibilities, and physician oversight as well as billing implications, care outcomes and medicolegal implications.

Healthcare in transition in the Republic of Armenia: the evolution of emergency medical systems and directions forward.

Armenia, an ex-Soviet Republic in transition since independence in 1991, has made remarkable strides in development. The crisis of prioritization that has plagued many post-Soviet republics in transition has meant differential growth in varied sectors in Armenia. Emergency systems is one of the sectors which is neglected in the current drive to modernize. The legacy of the Soviet Semashko system has left a void in specialized care including emergency care. This manuscript is a descriptive overview of the current state of emergency care in Armenia using in-depth key informant interviews and review of published and unpublished internal United States Agency for International Development (USAID) and Ministry of Health (MOH) documents as well as data from the Yerevan Municipal Ambulance Service and international agencies. The Republic of Artsakh is briefly discussed.The development of emergency care systems is an extremely efficient way to provide care across many different conditions in many age groups. Conditions such as traumatic injuries, heart attacks, cardiac arrest, stroke, and respiratory failure are very time-dependent. Armenia has a decent emergency infrastructure in place and has the benefit of an educated and skilled physician workforce. The missing piece of the puzzle appears to be investment in graduate and post-graduate education in emergency care and development of hospital-based emergency care for stabilization of stroke, myocardial infarction, trauma, and sepsis as well as other acute conditions.

Violation of the Global Ceasefire in Nagorno-Karabagh: A Viral Amplification of Aggression.

On March 23, 2020, the United Nations (UN) made an "Appeal for a Global Ceasefire following the Outbreak of Coronavirus." Despite this appeal, the Nagorno-Karabagh war was instigated on September 27, 2020. This Guest Editorial frames the conflict in the context of the UN appeal and by introducing a figure that plots seven-day average coronavirus disease 2019 (COVID-19) cases overlaid with key inflection points to illustrate the clear impact that conflict has had on pandemic spread in Armenia. The conflict in Nagorno-Karabagh provides a timely, concise, and illustrative example of conflict and its impact on health. Finally, an argument is made that the ability to enforce the UN "Appeal for a Global Ceasefire" is essential to ensure global health and security.

Association between patient-physician gender concordance and patient experience scores. Is there gender bias?

BACKGROUND: Patient satisfaction, a commonly measured indicator of quality of care and patient experience, is often used in physician performance reviews and promotion decisions. Patient satisfaction surveys may introduce gender-related bias. OBJECTIVE: Examine the effect of patient and physician gender concordance on patient satisfaction with emergency care. METHODS: We performed a cross-sectional analysis of electronic health record and Press Ganey patient satisfaction survey data of adult patients discharged from the emergency department (2015-2018). Logistic regression models were used to examine relationships between physician gender, patient gender, and physician-patient gender dyads. Binary outcomes included: perfect care provider score and perfect overall assessment score. RESULTS: Female patients returned surveys more often (n=7 612; 61.55%) and accounted for more visits (n=232 024; 55.26%). Female patients had lower odds of perfect scores for provider score and overall assessment score (OR: 0.852, 95% CI: 0.790, 0.918; OR: 0.782, 95% CI: 0.723, 0.846). Female physicians had 1.102 (95% CI: 1.001, 1.213) times the odds of receiving a perfect provider score. Physician gender did not influence male patients' odds of reporting a perfect care provider score (95% CI: 0.916, 1.158) whereas female patients treated by female physicians had 1.146 times the odds (95% CI: 1.019, 1.289) of a perfect provider score. CONCLUSION: Female patients prefer female emergency physicians but were less satisfied with their physician and emergency department visit overall. Over-representation of female patients on patient satisfaction surveys introduces bias. Patient satisfaction surveys should be deemphasized from physician compensation and promotion decisions.

A post-Soviet Republic in Transition: A Novel Amplification Programme to Address the Crisis of Continuing Medical Education and Challenges Facing Regional Physicians in the Republic of Armenia.

BACKGROUND: After the fall of the Soviet Union in 1991, the existing process of Continuing Medical Education (CME) was decimated. The Fund for Armenian Relief (FAR) was able to leverage competitive educational fellowship programmes in existence, and harness new knowledge gained by returning fellows thus amplifying the impact on education and patient care in the regions of the republic of Armenia. AIMS: This manuscript describes a replicable novel amplification programme using a "train the trainer" model for CME in the republic of Armenia. We sought to identify challenges specific to physicians from the regions, and to examine the strengths of the CME programme that can serve as a model for programme development and improvement in countries facing similar challenges. METHODS: The manuscript details a descriptive and mixed method study that includes in-depth interviews and focus group discussions from 2015-2016. Conceptual content analysis was used to identify major themes from the transcripts. RESULTS: Challenges facing regional physicians in post-Soviet counties in transition, exemplified by Armenia, are profound. Exploration of themes related to perceived barriers to care in the regions included, physicians' personal financial constraints, lack of up-to-date knowledge and equipment, lack of confidence, fear of criticism and of making incorrect diagnoses. CONCLUSIONS: The FAR/CME programme presents an innovative way to amplify the knowledge of Armenian physicians upon their return from educational programme participation abroad in order to address challenges facing regional physicians.

Continuing Medical Education and Continuing Professional Development in the Republic of Armenia: The Evolution of Legislative and Regulatory Frameworks Post Transition.

The collapse of the Soviet Union in 1991 left many ex-republics in a financial and administrative crisis for the ensuing two decades. Previously centralised processes like recertification of doctors and healthcare workers and continuing medical education fell by the wayside. Continuing medical education and continuing professional development in Armenia have evolved through multiple phases from Soviet, to immediate, mid and late-transitional post-Soviet periods, to current modernising efforts. This manuscript describes the phases of evolution of continuing medical education chronologically and details the legislative and regulatory framework surrounding each stage of development. Armenia is currently implementing a credit system of continuing medical education with the aim to introduce and adopt new and efficient approaches in this field. Continuing education credits fall into three categories: didactic or theoretical knowledge, practical skills and self-education/self-development. To recertify, professionals must collect credits from all three groups with specified minimum amounts according to their degrees. Armenia's guiding principle is to harmonise the continuing medical education and professional development model with internationally accepted criteria in order to contribute to the international mobility of healthcare workers and to provide for true on-going professional development and knowledge that will benefit our doctors, nurses and above all our patients.

Implementation of a Physician Assistant Emergency Medicine Residency Within a Physician Residency.

Physician assistants (PA) are an important part of emergency department healthcare delivery and are increasingly seeking specialty-specific postgraduate training. Our goal was to pilot the implementation of a PA postgraduate program within an existing physician residency program and produce emergency medicine-PA (EM-PA) graduates of comparable skill to their physician counterparts who have received the equivalent length of EM residency training to date (evaluated at the end of first year of EM training).The curriculum was based on the Society for Emergency Medicine Physician Assistants (SEMPA) recommendations with a special focus on side-by-side training with EM resident physicians. In reviewing the program, the authors examined faculty evaluations, as well as procedure and ultrasound experience that the trainees received. We found comparable evaluations between first-year EM-PA and physician trainee cohorts. This program serves as a pilot study to demonstrate the feasibility of collocating clinical and didactic programming for physicians and EM-PAs during their postgraduate training. This brief innovation report outlines the logistics of the clinical and didactic curriculum and provides a summary of outcomes evaluated.

Applying advanced analytics to guide emergency department operational decisions: A proof-of-concept study examining the effects of boarding.

BACKGROUND: Emergency Department (ED) leaders are increasingly confronted with large amounts of data with the potential to inform and guide operational decisions. Routine use of advanced analytic methods may provide additional insights. OBJECTIVES: To examine the practical application of available advanced analytic methods to guide operational decision making around patient boarding. METHODS: Retrospective analysis of the effect of boarding on ED operational metrics from a single site between 1/2015 and 1/2017. Times series were visualized through decompositional techniques accounting for seasonal trends, to determine the effect of boarding on ED performance metrics and to determine the impact of boarding "shocks" to the system on operational metrics over several days. RESULTS: There were 226,461 visits with the mean (IQR) number of visits per day was 273 (258-291). Decomposition of the boarding count time series illustrated an upward trend in the last 2-3 quarters as well as clear seasonal components. All performance metrics were significantly impacted (p<0.05) by boarding count, except for overall Press Ganey scores (p<0.65). For every additional increase in boarder count, overall length-of-stay (LOS) increased by 1.55min (0.68, 1.50). Smaller effects were seen for waiting room LOS and treat and release LOS. The impulse responses indicate that the boarding shocks are characterized by changes in the performance metrics within the first day that fade out after 4-5days. CONCLUSION: In this study regarding the use of advanced analytics in daily ED operations, time series analysis provided multiple useful insights into boarding and its impact on performance metrics.