Horizontal Violence Toward Emergency Medicine Residents: Gender as a Risk Factor.

INTRODUCTION: Horizontal violence (HV) is defined as "persistent exposure to interpersonal aggression and mistreatment from colleagues." Our objective in this pilot, single-site study was to identify sources of HV toward emergency medicine (EM) residents, using the Negative Acts Questionnaire-Revised (NAQ-R). METHODS: In this investigation we used a descriptive cross-sectional survey design to categorize HV. All voluntary participants were residents in an Accreditation Council for Graduate Medical Education-approved, three-year academic EM residency. Data were collected via electronic survey and occurred six months into an academic year. We collected demographic information and responses to the NAQ-R in 2020. Horizontal violence is subdivided into three categories: work-related; person-related; and physical intimidation. Emergency medicine residents answered questions as they related to their interactions with residents and support staff, which included nursing. RESULTS: A total of 23 of 26 residents responded (89%). Participants were 56% women, 78% white, 11% Hispanic, and 89% heterosexual. Participant clinical year was 39% first-, 39% second-, and 22% third-year residents. Women reported a higher frequency of HV compared to men (1.3 vs 1.1, P =.01). By category, women indicated higher incidence of work-related violence from other residents (P = .05) and staff (P =.02). There was no difference in reported frequency of violence for interns compared to senior residents. CONCLUSION: Our pilot study demonstrated horizontal violence toward EM residents exists and is more prevalent in women.

Progression of Emergency Medicine Resident Patient Experience Scores by Level of Training.

BACKGROUND: Patient satisfaction surveys are vital to measuring a patient's experience of care. How scores of patients managed by emergency medicine (EM) residents change as residents progress through training is not known. OBJECTIVES: To evaluate whether EM residents' patient satisfaction scores improve as residency training progresses, similar to clinical skill improvement. METHODS: A retrospective cross-sectional study evaluated the correlation of patient satisfaction scores with EM resident year of training from 2015 through 2017. We evaluated for a change in score over time for the 4 "physician questions" and the "overall" score. RESULTS: We evaluated 1684 Press Ganey surveys linked to 40 EM resident physicians during the study period. The mean top box scores for the 4 physician questions (concern for comfort [P = .72], courtesy [P = .55], informative about treatment [P = .46], and listening [P = .91]) and overall assessment of emergency department care (P = .51) were not significantly improved over the course of resident. CONCLUSION: We did not observe a difference in EM residents' patient experience scores as their level of training progressed. Comprehensive patient experience training for residents might be needed.

Bridging the gap to effective feedback in residency training: perceptions of trainees and teachers.

BACKGROUND: Clinical feedback is an important part of residency training, yet literature suggests this complex interaction is not completely understood. In particular, little is known about what resident versus attending physicians expect as feedback. This study investigates this gap in knowledge by examining differences in interactions that residents and attendings view as feedback. METHODS: Surveys containing sample clinical feedback scenarios were distributed to residents and attending physicians in emergency medicine and general surgery at a large academic medical center. Respondents were asked to decide whether useful feedback was provided in each scenario, and responses were compared between the two groups. Continuous features were summarized with medians, interquartile ranges (IQRs), and ranges; categorical features were summarized with frequency counts and percentages. Comparisons of features between residents and attendings were evaluated using Wilcoxon rank sum, chi-square, and Fisher exact tests. Statistical analyses were performed using version 9.4 of the SAS software package (SAS Institute, Inc.; Cary, NC). All tests were two-sided and p-values < 0.05 were considered statistically significant. RESULTS: Seventy-two individuals responded to the survey out of approximately 110 invitations sent (65%), including 35 (49%) residents and 37 (51%) attendings. Of 35 residents, 31 indicated their level of training, which included 13 (42%) PGY-1, 9 (29%) PGY-2, 6 (19%) PGY-3, and 3 (10%) PGY-4, respectively. Of 37 attendings, 34 indicated the number of years since completion of residency or last fellowship, at a median of 9 years (IQR 4-14; range 1-31). No significant difference was found in residents' and attendings' perceptions of what constituted feedback in the sample scenarios. CONCLUSIONS: While this study did not find a statistical difference in perception of feedback between residents and attendings, additional factors should be considered when investigating perceived feedback deficiencies. Further research is needed to better understand and improve the clinical feedback process.

Perceptions of the 2011 ACGME duty hour requirements among residents in all core programs at a large academic medical center.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) implemented revisions to resident duty hour requirements (DHRs) in 2011 to improve patient safety and resident well-being. Perceptions of DHRs have been reported to vary by training stage and specialty among internal medicine and general surgery residents. The authors explored perceptions of DHRs among all residents at a large academic medical center. METHODS: The authors administered an anonymous cross-sectional survey about DHRs to residents enrolled in all ACGME-accredited core residency programs at their institution. Residents were categorized as medical and pediatric, surgery, or other. RESULTS: In total, 736 residents representing 24 core specialty residency programs were surveyed. The authors received responses from 495 residents (67%). A majority reported satisfaction (78%) with DHRs and believed DHRs positively affect their training (73%). Residents in surgical specialties and in advanced stages of training were significantly less likely to view DHRs favorably. Most respondents believed fatigue contributes to errors (89%) and DHRs reduce both fatigue (80%) and performance of clinical duties while fatigued (74%). A minority of respondents (37%) believed that DHRs decrease medical errors. This finding may reflect beliefs that handovers contribute more to errors than fatigue (41%). Negative perceived effects included diminished patient familiarity and continuity of care (62%) and diminished clinical educational experiences for residents (41%). CONCLUSIONS: A majority of residents reported satisfaction with the 2011 DHRs, although satisfaction was significantly less among residents in surgical specialties and those in advanced stages of training.

Gender Distribution Among American Board of Medical Specialties Boards of Directors.

Since 1995, women have comprised more than 40% of all medical school graduates. However, representation at leadership levels in medicine remains considerably lower. Gender representation among the American Board of Medical Specialties (ABMS) boards of directors (BODs) has not previously been evaluated. Our objective was to determine the relative representation of women on ABMS BODs and compare it with the in-training and in-practice gender composition of the respective specialties. The composition of the ABMS BODs was obtained from websites in March 2016 for all Member Boards. Association of American Medical Colleges and American Medical Association data were utilized to identify current and future trends in gender composition. Although represented by a common board, neurology and psychiatry were evaluated separately because of their very different practices and gender demographic characteristics. A total of 25 specialties were evaluated. Of the 25 specialties analyzed, 12 BODs have proportional gender representation compared with their constituency. Seven specialties have a larger proportion of women serving on their boards compared with physicians in practice, and 6 specialties have a greater proportion of men populating their BODs. Based on the most recent trainee data (2013), women have increasing workforce representation in almost all specialties. Although women in both training and practice are approaching equal representation, there is variability in gender ratios across specialties. Directorship within ABMS BODs has a more equitable gender distribution than other areas of leadership in medicine. Further investigation is needed to determine the reasons behind this difference and to identify opportunities to engage women in leadership in medicine.

Teaching and clinical efficiency: competing demands.

INTRODUCTION: Teaching ability and efficiency of clinical operations are important aspects of physician performance. In order to promote excellence in education and clinical efficiency, it would be important to determine physician qualities that contribute to both. We sought to evaluate the relationship between teaching performance and patient throughput times. METHODS: The setting is an urban, academic emergency department with an annual census of 65,000 patient visits. Previous analysis of an 18-question emergency medicine faculty survey at this institution identified 5 prevailing domains of faculty instructional performance. The 5 statistically significant domains identified were: Competency and Professionalism, Commitment to Knowledge and Instruction, Inclusion and Interaction, Patient Focus, and Openness and Enthusiasm. We fit a multivariate, random effects model using each of the 5 instructional domains for emergency medicine faculty as independent predictors and throughput time (in minutes) as the continuous outcome. Faculty that were absent for any portion of the research period were excluded as were patient encounters without direct resident involvement. RESULTS: Two of the 5 instructional domains were found to significantly correlate with a change in patient treatment times within both datasets. The greater a physician's Commitment to Knowledge and Instruction, the longer their throughput time, with each interval increase on the domain scale associated with a 7.38-minute increase in throughput time (90% confidence interval [CI]: 1.89 to 12.88 minutes). Conversely, increased Openness and Enthusiasm was associated with a 4.45-minute decrease in throughput (90% CI: -8.83 to -0.07 minutes). CONCLUSION: Some aspects of teaching aptitude are associated with increased throughput times (Openness and Enthusiasm), while others are associated with decreased throughput times (Commitment to Knowledge and Instruction). Our findings suggest that a tradeoff may exist between operational and instructional performance.

The "good" dean's letter.

PURPOSE: To determine whether a correlation exists between the term "good" on the summative, comparative assessment of a student's Medical Student Performance Evaluation (MSPE) and his or her actual performance in medical school. METHOD: The authors reviewed the MSPEs submitted to three residency programs to determine the presence of the term "good" in either the summary paragraph or the appendices. Next, they noted, for institutions using "good," the percentile rankings of those students who received "good" as a descriptor. To examine the consistency among institutions regarding the percentile ranking denoted by "good," they dichotomized the data into students below and above the bottom 25th percentile. They analyzed the data using a nonparametric test because of their nonnormal distribution. RESULTS: The authors collected MSPEs from 122 of the 125 Liaison Committee on Medical Education-accredited medical schools that were graduating students in 2008. Of these 122 institutions, 34 (28%) used the term "good." All 34 institutions used the term to characterize students in the bottom 50% of the graduating class. The authors found a significant difference in the percentile ranking of students described as "good" between institutions using it to describe the bottom 25% and institutions using the term to describe those in the 25th to 50th percentiles (median ranking of 12.5% versus 30%, P < .0001). CONCLUSIONS: Overall, the term "good" in the MSPE describes students in the bottom 50% of the class; therefore, the term "good," as used to describe performance in medical school, consistently indicates below-average performance.

The management of children with gastroenteritis and dehydration in the emergency department.

BACKGROUND: Acute gastroenteritis is characterized by diarrhea, which may be accompanied by nausea, vomiting, fever, and abdominal pain. OBJECTIVE: To review the evidence on the assessment of dehydration, methods of rehydration, and the utility of antiemetics in the child presenting with acute gastroenteritis. DISCUSSION: The evidence suggests that the three most useful predictors of 5% or more dehydration are abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern. Studies are conflicting on whether blood urea nitrogen (BUN) or BUN/creatinine ratio correlates with dehydration, but several studies found that low serum bicarbonate combined with certain clinical parameters predicts dehydration. In most studies, oral or nasogastric rehydration with an oral rehydration solution was equally efficacious as intravenous (i.v.) rehydration. Many experts discourage the routine use of antiemetics in young children. However, children receiving ondensetron are less likely to vomit, have greater oral intake, and are less likely to be treated by intravenous rehydration. Mean length of Emergency Department (ED) stay is also less, and very few serious side effects have been reported. CONCLUSIONS: In the ED, dehydration is evaluated by synthesizing the historical and physical examination, and obtaining laboratory data points in select patients. No single laboratory value has been found to be accurate in predicting the degree of dehydration and this is not routinely recommended. The evidence suggests that the majority of children with mild to moderate dehydration can be treated successfully with oral rehydration therapy. Ondansetron (orally or intravenously) may be effective in decreasing the rate of vomiting, improving the success rate of oral hydration, preventing the need for i.v. hydration, and preventing the need for hospital admission in those receiving i.v. hydration.

Developing a standardized faculty evaluation in an emergency medicine residency.

BACKGROUND: Quality educators are a core component of successful residency training. A structured, consistent, validated evaluation of clinical educators is important to improve teaching aptitude, further faculty development, and improve patient care. STUDY OBJECTIVES: The authors sought to identify specific domains of instructional quality and to develop a composite instrument for assessing instructional quality. METHODS: The study setting is a 3-year residency program. Residents rated the quality of faculty member instruction using an 18-item survey twice over a 2-year period (2004-2005). Each survey item used a 9-point scale. Factor analysis employing a Varimax rotation identified domains of instructional performance. Cronbach's alpha was used to assess the internal consistency of the identified domains. RESULTS: There were 29 faculty members evaluated. Using 2004 data, five domains of instructional quality were identified that explained 92.5% of the variation in survey responses (χ(2) = 2.33, P = 0.11). These were: Competency and Professionalism (30% of variation), Commitment to Knowledge and Instruction (23%), Inclusion and Interaction (17%), Patient Focus (13%), and Openness to Ideas (9%). Competency and Professionalism included appropriate care, effective patient communication, use of new techniques, and ethical principles. Commitment to Knowledge and Instruction included research, mentoring, feedback, and availability. Inclusion and Interaction included procedural participation and bedside teaching. Patient Focus included compassion, effective care, and sensitivity to diverse populations. Openness to Ideas included enthusiasm and receptivity of new ideas. These five domains were consistent in the 2005 data (Cronbach's alpha 0.68-0.75). CONCLUSIONS: A five-domain instrument consistently accounted for variations in faculty teaching performance as rated by resident physicians. This instrument may be useful for standardized assessment of instructional quality.

Pediatric emergency medicine fellowships: faculty and resident training profiles.

The objective of this study was to evaluate the faculty and graduate training profiles of Pediatric Emergency Medicine (PEM) fellowship training programs. An electronic 10-point questionnaire was sent to 57 PEM fellowship directors, with a 70% response rate. Analysis of the individual certification of faculty members in PEM training programs demonstrated that the largest represented training types were general pediatricians and pediatricians with PEM sub-certification (29% and 62% representation, respectively). The remaining faculty types consistently showed < 5% overall involvement. Reported estimates on faculty delivery of clinical training, didactic training, and procedural skills demonstrated that pediatricians sub-board certified in PEM consistently administered the highest percentage of these skill sets (74%, 68%, and 68%, respectively). Emergency Medicine-trained physicians showed a relative increase of involvement in fellowship programs administered by Emergency Medicine departments and in those programs located within adult hospitals. Yet, this involvement still remained substantially lower than that of the pediatric-type faculty. Program directors of fellowships within pediatric hospitals and those administered by Pediatric programs demonstrated a preference for general pediatricians with sub-board certification in PEM to improve their faculty pools. Program directors of fellowship programs located in adult hospitals and those administered by departments of EM demonstrated no preference in training type. Lastly, program directors report that 95% of past graduates received their primary board certification through Pediatrics and only 5% received their primary board certification through Emergency Medicine. There are currently many more pediatric-trained physicians among PEM fellowship faculty and graduates. This survey has demonstrated that there has been a decline in EM-trained physicians involved in PEM fellowships since 2000.

Pediatric myth: fever and petechiae.

A child presenting with petechiae and fever is assumed to have meningococcemia or another form of bacterial sepsis and therefore to require antibiotics, blood cultures, cerebrospinal fluid analysis and hospital admission. A review of the literature challenges this statement and suggests that a child presenting with purpura (or petechiae), an ill appearance and delayed capillary refill time or hypotension should be admitted and treated for meningococcal disease without delay. Conversely, a child with a petechial rash, which is confined to the distribution of the superior vena cava, is unlikely to have meningococcal disease. Outpatient therapy in this context is appropriate. In other children, a reasonable approach would be to draw blood for culture and C-reactive protein (CRP) while administering antibiotics. If the CRP is normal, these children could be discharged to follow-up in 1 day, whereas children with CRP values greater than 6 mg/L would be admitted.

An emergency medicine approach to neonatal hyperbilirubinemia.

Jaundice (also known as hyperbilirubinemia) is a yellowish-greenish pigmentation of the sclera and skin caused by an increase in bilirubin production or a defect in bilirubin elimination. Management of hyperbilirubinemia is one of the most common reasons for readmission of a newborn. Prolonged unconjugated hyperbilirubinemia can result in acute bilirubin encephalopathy and eventually develop into chronic bilirubin encephalopathy (kernicterus). Kernicterus, the feared complication of hyperbilirubinemia, was considered almost extinct but has recently re-emerged despite virtual elimination of Rh disease. This review provides a systematic approach to the presentation, evaluation, and management of the jaundiced newborn.

Brain natriuretic peptide (BNP) testing in the emergency department.

In the past decade a large amount of attention has been focused on brain natriuretic peptide (BNP) testing in the evaluation of patients with acute dyspnea as well as the screening of patients for congestive heart failure (CHF). Because BNP is secreted by myocytes in response to ventricular stretch, it has long been thought that BNP could become a biochemical marker for CHF. Rapid assays have been developed and BNP testing has been studied in detection of CHF and predictive outcomes in a large variety of settings. We review the clinical evidence associated with the use of BNP testing in the acute care setting. We conclude with a discussion of clinical utility in the emergency department for the evaluation of patients presenting with acute dyspnea.

Pediatric blunt abdominal trauma.

Blunt pediatric trauma is a major threat to the health and well-being of children. Nationwide, many practitioners care for children who face this issue. Some key principles related to the evaluation and management of these children are elucidated in this article.