How to HEEAL: A Patient and Peer-Centric Simulation Curriculum for Medical Error Disclosure.

Introduction: Medical errors are an unfortunate certainty with emotional and psychological consequences for patients and health care providers. No standardized medical curriculum on how to disclose medical errors to patients or peers exists. The novel HEEAL (honesty/empathy/education/apology-awareness/lessen chance for future errors) curriculum addresses this gap in medical education through a multimodality workshop. Methods: This 6-hour, two-part curriculum incorporated didactic and standardized patient (SP) simulation education with rapid cycle deliberate practice (RCDP). The morning focused on provider-patient error disclosure; the afternoon applied the same principles to provider-provider (peer) discussion. Summative simulations with SPs evaluated learners' skill baseline and improvement. Formative simulations run by expert simulation educators used RCDP to provide real-time feedback and opportunities for adjustment. Medical knowledge was measured through pre- and postintervention multiple-choice questions. Learners' confidence and attitude towards medical errors disclosure were surveyed pre- and postintervention with assistance of the Barriers to Error Disclosure Assessment tool, revised with the addition of several questions related to provider-provider disclosure. Results: Fourteen medical students participated in this pilot curriculum. Statistical significance was demonstrated in medical knowledge (p = .01), peer-disclosure skills (p = .001), and confidence in medical error disclosure (p < .001). Although there was improvement in patient-disclosure skills, this did not reach statistical significance (p = .05). Discussion: This curriculum addresses the need for designated training in medical error disclosure. Learners gained knowledge, skills, and confidence in medical error disclosure. We recommend this curriculum for medical students preparing for transition to residency.

Resilience Building Practices for Women Physicians.

Women now make up more than half of the physician workforce, but they are disproportionately plagued by burnout. Medicine is a fast-paced stressful field, the practice of which is associated with significant chronic stress due to systems issues, crowding, electronic medical records, and patient case mix. Hospitals and health care systems are responsible for mitigating system-based burnout-prone conditions, but often their best efforts fail. Physicians, particularly women, must confront their stressors and the daily burden of significant system strain when this occurs. Those who routinely exceed their cumulative stress threshold may experience burnout, career dissatisfaction, and second victim syndrome and, ultimately, may prematurely leave medicine. These conditions affect women in medicine more often than men and may also produce a higher incidence of health issues, including depression, substance use disorder, and suicide. The individual self-care required to maintain health and raise stress thresholds is not widely ingrained in provider practice patterns or behavior. However, the successful long-term practice of high-stress occupations, such as medicine, requires that physicians, especially women physicians, attend to their wellness. In this article, we address one aspect of health, resilience, and review six practices that can create additional stores of personal resilience when proactively integrated into a daily routine.

Career Advancement Among Women Physicians in Nine Academic Medicine Specialties.

Objective: Gender parity lags in academic medicine. We applied the Rank Equity Index (REI) to compare the longitudinal progress of women's academic medicine careers. We hypothesized that women have different rank parity in promotion by specialty based on the proportion of women in the specialty. Materials and Methods: Aggregate data by sex for medical students, residents, assistant professors, associate professors, and professors in nine specialties were obtained from the Association of American Medical Colleges for 2019-2020. Specialties were clustered into terciles based on the proportion of women in the field: upper (obstetrics and gynecology, pediatrics, psychiatry), middle (internal medicine, emergency medicine, anesthesia), and lower (surgery, urology, and orthopedic surgery). We calculated the percentage representation by sex by specialty and rank to calculate REI. Specialty-specific REI comparisons between each rank were performed to assess parity in advancement. Results: Only specialties in the upper tercile recruited proportionally more women medical students to residency training. All specialties advanced women for the resident-to-assistant professor with psychiatry, internal medicine, emergency medicine, anesthesia, urology, and orthopedic surgery that promoted women faculty at rates above parity. No specialty demonstrated parity in advancement based on sex for the assistant professor-to-associate professor or associate professor-to-professor transitions. Conclusion: Gender inequity in advancement is evident in academic medicine starting at the assistant professor-to-associate professor stage, regardless of overall proportion of women in the specialty. This suggests a common set of barriers to career advancement of women faculty in academic medicine that must be addressed starting at the early career stage.

Closing the gender gap in medicine: the impact of a simulation-based confidence and negotiation course for women in graduate medical education.

BACKGROUND: Currently, 75-80% of the medical workforce worldwide consists of women. Yet, women comprise 21% of full professors and less than 20% of department chairs and medical school deans. Identified causes of gender disparities are multifactorial including work-life responsibilities, gender discrimination, sexual harassment, bias, lack of confidence, gender differences in negotiation and leadership emergence, and lack of mentorship, networking, and/or sponsorship. A promising intervention for the advancement of women faculty is the implementation of Career Development Programs (CDPs). Women physician CDP participants were shown to be promoted in rank at the same rate as men by year five, and more likely to remain in academics after eight years compared to both men and women counterparts. The objective of this pilot study is to investigate the effectiveness of a novel, simulation-based, single-day CDP curriculum for upper-level women physician trainees to teach communication skills identified as contributing to medicine's gender advancement gap. METHODS: This was a pilot, pre/post study performed in a simulation center implementing a curriculum developed to educate women physicians on 5 identified communication skills recognized to potentially reduce the gender gap. Pre- and post-intervention assessments included confidence surveys, cognitive questionnaires, and performance action checklists for five workplace scenarios. Assessment data were analyzed using scored medians and descriptive statistics, applying Wilcoxon test estimation to compare pre- versus post-curriculum intervention scores, with p < 0.05 considered statistically significant. RESULTS: Eleven residents and fellows participated in the curriculum. Confidence, knowledge, and performance improved significantly after completion of the program. Pre-confidence: 28 (19.0-31.0); Post-confidence: 41 (35.0-47.0); p < 0.0001. Pre-knowledge: 9.0 (6.0-11.00); Post knowledge: 13.0 (11.0-15.0); p < 0.0001. Pre-performance: 35.0 (16.0-52.0); Post-performance: 46.0 (37-53.00); p < 0.0001. CONCLUSION: Overall, this study demonstrated the successful creation of a novel, condensed CDP curriculum based on 5 identified communication skills needed for women physician trainees. The post-curriculum assessment demonstrated improved confidence, knowledge, and performance. Ideally, all women medical trainees would have access to convenient, accessible, and affordable courses teaching these crucial communication skills to prepare them for careers in medicine to strive to reduce the gender gap.

Physician Men Leaders in Emergency Medicine Bearing Witness to Gender-Based Discrimination.

Importance: Approximately 60% of women physicians in emergency medicine (EM) experience gender-based discrimination (GBD). Women physicians are also more likely to experience GBD than men physicians, particularly from patients, other physicians, or nursing staff. Objective: To describe the responses of men who are academic department chairs in EM to GBD directed toward a woman colleague. Design, Setting, and Participants: This qualitative study was a secondary data analysis drawn from interviews of men EM academic department chairs at 18 sites who participated in a qualitative descriptive study between April 2020 and February 2021 on their perceptions of the influence of gender and leadership in academic medicine. Narrative data related to GBD were extracted and coded using conventional content analysis. Codes were clustered into themes and subthemes and summarized. Data were analyzed from November to December 2021. Exposure: Semistructured interviews conducted via teleconferencing. Main Outcomes and Measures: Qualitative findings identifying experiences witnessing or learning about incidents of GBD against women colleagues, the impact of these observations, and personal or leadership actions taken in response to their observations. Results: All 18 men participants (mean [SD] age, 52.2 [7.5] years; mean [SD] time as a department chair, 7.2 [5.1] years) discussed witnessing or learning about incidents of GBD against women colleagues. The participant narratives revealed 3 themes: emotional responses to GBD, actions they took to address GBD, and reasons for not taking action to address GBD. When witnessing GBD, participants felt anger, disbelief, guilt, and shame. To take action, they served as upstanders, confronted and reported discrimination, provided faculty development on GBD, or enforced "zero-tolerance" policies. At times they did not take action because they did not believe the GBD warranted a response, perceived a power differential or an unsupportive institutional culture, or sought self-preservation. Conclusions and Relevance: In this qualitative study of men physician leaders, we found all participants reported feeling troubled by GBD against women colleagues and, if possible, took action to address the discrimination. At times they did not take action because of unsupportive workplace cultures. These findings suggest that institutional culture change that supports the interventions of upstanders and does not tolerate GBD is needed.

Barriers, Challenges, and Solutions: What Can We Learn About Leadership in Academic Medicine From a Qualitative Study of Emergency Medicine Women Chairs?

PURPOSE: Women have made significant gains in leadership across all disciplines in academic medicine but have not yet achieved leadership parity as department chairs. The authors investigated the challenges experienced by one cohort of women department chairs in emergency medicine (EM) and the solutions they proposed to address these challenges. METHOD: The authors conducted a qualitative descriptive study of 19 of 20 possible current and emeritus emergency medicine women department chairs at academic medical centers between April and December 2020. Participant interviews elicited self-reported demographic characteristics and narrative responses to a semistructured interview template that focused on the role of gender in their leadership and career trajectories. Interviews were transcribed, blinded, and iteratively coded and categorized. RESULTS: The analysis demonstrated 4 common challenges and 5 enacted or proposed solutions. The challenges discussed by the participants were: feeling unprepared for the role of department chair, being one of few women in leadership, inheriting unhealthy department cultures, and facing negative faculty reactions. The individual- and institutional-level solutions discussed by the participants were: gaining and maintaining confidence (individual), maintaining accountability and mission alignment (individual), facilitating teamwork (individual), supporting women's leadership (institution), and creating safe leadership cultures (institution). CONCLUSIONS: Women department chairs in EM were successful academic leaders despite confronting several challenges to their leadership. Considering the study findings through the lens of the concept of second-generation gender bias further illuminates the influence of gender on leadership in academic medicine. These findings suggest several possible strategies that can combat gender bias, increase gender parity among academic medicine's leadership, and improve the leadership experience for women leaders.

Gender Differences in Experiences of Leadership Emergence Among Emergency Medicine Department Chairs.

Importance: The number of women entering medicine continues to increase, but women remain underrepresented at all tiers of academic rank and chair leadership in EM. The proportion of female chairs in EM has not exceeded 12% in 2 decades. Objective: To compare how male and female EM chairs experience leadership emergence, with attention to factors associated with support of the emergence of female chairs. Design, Setting, and Participants: This qualitative descriptive study was conducted between April 2020 and February 2021 at 36 US academic EM departments. Eligible participants were all current and emeritus female EM academic department chairs (with a possible cohort of 20 individuals) and an equal number of randomly selected male chairs. Interventions: Semistructured interviews were conducted via teleconferencing with an 11-item interview guide. Main Outcomes and Measures: Qualitative findings identifying similarities and gender differences in leadership emergence were collected. Results: Among 20 female chairs in EM, 19 women (mean [SD] age, 56.2 [7.1] years) participated in the study (95.0% response rate). There were 13 active chairs, and 6 women were within 5 years of chair leadership. Among 77 male chairs in EM identified and randomized, 37 men were invited to participate, among whom 19 individuals (51.4%) agreed to participate; 18 men (mean [SD] age, 52.2 [7.5] years) completed their interviews. Reflecting upon their experiences of leadership emergence, male chairs saw leadership as their destiny, were motivated to be chairs to gain influence, were dismissive of risks associated with chairing a department, and were sponsored by senior male leaders to advance in leadership. Female chairs saw leadership as something they had long prepared for, were motivated to be chairs to make a difference, were cautious of risks associated with chairing a department that could derail their careers, and relied on their own efforts to advance in leadership. Conclusions and Relevance: This study found that experiences of leadership emergence differed by gender. These results suggest that leadership development strategies tailored to women should promote early internalization of leadership identity, tightly link leadership to purpose, cultivate active sponsorship, and encourage women's risk tolerance through leadership validation to support women's development as leaders and demonstrate a commitment to gender equity in EM leadership.

Adaptive change in simulation education: Comparison of effectiveness of a communication skill curriculum on death notification using in person methods versus a digital communication platform.

Background: Mandates to social distance and "shelter in place" during the COVID-19 pandemic necessitated the exploration of new academic content delivery methods. Digital communication platforms (DCP; e.g., Zoom) were widely used to facilitate content delivery, yet little is known about DCP's capacity or effectiveness, especially for simulation. Objective: The objective was to compare the experience, outcomes, and resources required to implement a simulation-based communication skill curriculum on death notification to a cohort of learners using in-person versus DCP delivery of the same content. Methods: We used the GRIEV_ING mnemonic to train students in death notification techniques either in person or utilizing a DCP. For all learners, three measures were collected: knowledge, confidence, and performance. Individual learners completed knowledge and confidence assessments pre- and postintervention. All performance assessments were completed by standardized patients (SPs) in real time. Wilcoxon rank-sum test was used to identify differences in individual and between-group performances. Results: Thirty-four learners participated (N = 34), 22 in person and 12 via DCP. There was a statistically significant improvement in both groups for all three measures: knowledge, confidence, and performance. Between-group comparisons revealed a difference in pretest confidence but no differences between groups in knowledge or performance. More preparation and prior planning were required to set up the DCP environment than the in-person event. Conclusions: The in-person and DCP delivery of death notification training were comparable in their ability to improve individual knowledge, confidence, and performance. Additional preparation time, training, and practice with DCPs may be required for SPs, faculty, and learners less familiar with this technology.

Using the Rank Equity Index to measure emergency medicine faculty rank progression.

BACKGROUND: Faculty diversity is a high-priority goal for academic emergency medicine (EM). Most administrators currently monitor faculty diversity using aggregate data, which may obscure underrepresentation by rank. We apply the Rank Equity Index (REI) to EM faculty data to assess rank progression. METHODS: We calculated the REI (% faculty cohort higher rank/% faculty cohort lower rank) for EM faculty. We performed REI analyses by faculty gender (women, men) and race/ethnicity (White, Black, Hispanic/Latinx, Asian). We compared professor/assistant professor, professor/associate professor, and associate professor/assistant professor to establish rank parity for gender and race/ethnicity. Parity is an REI of 1.0. RESULTS: REI analysis by gender demonstrates that women faculty did not achieve parity at any rank comparison in any study year. REI analysis by race/ethnicity demonstrates that all faculty of color are below parity at the assistant to associate professor promotion. Latinx faculty are at parity for associate professor to professor, but Asian and Black faculty do not achieve parity in any comparison. Intersecting gender and race/ethnicity in the REI analysis demonstrates that Asian women have the lowest REIs among all faculty ranks and races/ethnicities. Men of all races/ethnicities achieved parity in two of three rank comparisons, except for Black men, who did not achieve parity in any comparison. CONCLUSIONS: REI analysis demonstrates EM women faculty and faculty of color are not achieving rank parity and are disadvantaged at the first tier of promotion. A preliminary longitudinal trend analysis suggests little progress. Asian women and Black men experience the most rank inequity. REI analysis identifies a need for focused faculty development to enhance our most vulnerable faculty's rank progression, suggesting that targeted recruitment and retention efforts of women faculty of all races/ethnicities and faculty of color, in particular, will improve diversity at every tier of faculty rank.

Setup and Execution of the Rapid Cycle Deliberate Practice Death Notification Curriculum.

Death notification is an important and challenging aspect of Emergency Medicine. An Emergency Medicine physician must deliver bad news, often sudden and unexpected, to patients and family members without any previous relationship. Unskilled death notification after unexpected events can lead to the development of pathologic grief and posttraumatic stress disorder. It is paramount for Emergency Medicine physicians to be trained in and practice death notification techniques. The GRIEV_ING curriculum provides a conceptual framework for death notification. The curriculum has demonstrated improvement in learners' confidence and competence when delivering bad news. Rapid Cycle Deliberate Practice is a simulation-based medical education technique that uses within the scenario debriefing. This technique uses the concepts of mastery learning and deliberate practice. It allows educators to pause a scenario, provide directed feedback, and then let learners continue the simulation scenario the "right way." The purpose of this scholarly work is to describe how to apply the Rapid Cycle Deliberate Practice debriefing technique to the GRIEV_ING death notification curriculum to more effectively train learners in the delivery of bad news.

Rapid-cycle deliberate practice: death notification.

BACKGROUND: Death notification can be challenging for emergency medicine physicians, who have no prior established relationship with the patient or their families. The GRIEV_ING death notification curriculum was developed to facilitate the delivery of the bad news of a patient's death and has been shown to improve learners' confidence and competence in death notification. Rapid-cycle deliberate practice (RCDP), a facilitator-guided, within-event debriefing technique, has demonstrated an improvement in learners' skills in a safe learning environment. The aim of this study was to identify whether the use of this technique is an effective method of teaching the GRIEV_ING curriculum, as demonstrated by learners' improved confidence, cognitive knowledge and performance. Rapid-cycle deliberate practice (RCDP), a facilitator-guided within-event, debriefing technique, has demonstrated an improvement in learners' skills in a safe learning environment METHODS: A 4-hour pilot curriculum was developed to educate and assess residents on the delivery of death notification. The curriculum consisted of a pre-intervention evaluation, the intervention phase, and a post-intervention evaluation. The cognitive test, critical action checklist, and self-efficacy/confidence surveys were identical for both pre- and post-intervention evaluations. A Wilcoxon rank-sum test was used to evaluate differences in scores between pre- and post-intervention groups. RESULTS: Twenty-two emergency medicine residents participated in the study. We observed an increase in median self-efficacy scores (4.0 [4.0-5.0], p ≤ 0.0001), multiple-choice GRIEV_ING scores (90.0 [80.0-90.0], p ≤ 0.0001) and performance scores for death notification (48.5 [47.0-53.0], p = 0.0303). DISCUSSION: The RCDP approach was found to be an effective method to train emergency medicine residents in the delivery of the GRIEV_ING death notification curriculum. This approach is actionable with few resources except for content experts trained in RCDP methodology and the application of the GRIEV_ING mnemonic.

The Vice Chair of Education in Emergency Medicine: A Workforce Study to Establish the Role, Clarify Responsibilities, and Plan for Success.

OBJECTIVES: Despite increasing prevalence in emergency medicine (EM), the vice chair of education (VCE) role remains ambiguous with regard to associated responsibilities and expectations. This study aimed to identify training experiences of current VCEs, clarify responsibilities, review career paths, and gather data to inform a unified job description. METHODS: A 40-item, anonymous survey was electronically sent to EM VCEs. VCEs were identified through EM chairs, residency program directors, and residency coordinators through solicitation e-mails distributed through respective listservs. Quantitative data are reported as percentages with 95% confidence intervals and continuous variables as medians with interquartiles (IQRs). Open- and axial-coding methods were used to organize qualitative data into thematic categories. RESULTS: Forty-seven of 59 VCEs completed the survey (79.6% response rate); 74.4% were male and 89.3% were white. Average time in the role was 3.56 years (median = 3.0 years, IQR = 4.0 years), with 74.5% serving as inaugural VCE. Many respondents held at least one additional administrative title. Most had no defined job description (68.9%) and reported no defined metrics of success (88.6%). Almost 78% received a reduction in clinical duties, with an average reduction of 27.7% protected time effort (median = 27.2%, IQR = 22.5%). Responsibilities thematically link to faculty affairs and promotion of the departmental educational mission and scholarship. CONCLUSION: Given the variability in expectations observed, the authors suggest the adoption of a unified VCE job description with detailed responsibilities and performance metrics to ensure success in the role. Efforts to improve the diversity of VCEs are encouraged to better match the diversity of learners.

Effect of an Educational Intervention on Medical Student Scripting and Patient Satisfaction: A Randomized Trial.

INTRODUCTION: Effective communication between clinicians and patients has been shown to improve patient outcomes, reduce malpractice liability, and is now being tied to reimbursement. Use of a communication strategy known as "scripting" has been suggested to improve patient satisfaction in multiple hospital settings, but the frequency with which medical students use this strategy and whether this affects patient perception of medical student care is unknown. Our objective was to measure the use of targeted communication skills after an educational intervention as well as to further clarify the relationship between communication element usage and patient satisfaction. METHODS: Medical students were block randomized into the control or intervention group. Those in the intervention group received refresher training in scripted communication. Those in the control group received no instruction or other intervention related to communication. Use of six explicit communication behaviors were recorded by trained study observers: 1) acknowledging the patient by name, 2) introducing themselves as medical students, 3) explaining their role in the patient's care, 4) explaining the care plan, 5) providing an estimated duration of time to be spent in the emergency department (ED), and 6) notifying the patient that another provider would also be seeing them. Patients then completed a survey regarding their satisfaction with the medical student encounter. RESULTS: We observed 474 medical student-patient encounters in the ED (231 in the control group and 243 in the intervention group). We were unable to detect a statistically significant difference in communication element use between the intervention and control groups. One of the communication elements, explaining steps in the care plan, was positively associated with patient perception of the medical student's overall communication skills. Otherwise, there was no statistically significant association between element use and patient satisfaction. CONCLUSION: We were unable to demonstrate any improvement in student use of communication elements or in patient satisfaction after refresher training in scripted communication. Furthermore, there was little variation in patient satisfaction based on the use of scripted communication elements. Effective communication with patients in the ED is complicated and requires further investigation on how to provide this skill set.

Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department.

OBJECTIVE: We assessed emergency department (ED) patient perceptions of how physicians can improve their language to determine patient preferences for 11 phrases to enhance physician empathy toward the goal of reducing low-value advanced imaging. METHODS: Multi-center survey study of low-risk ED patients undergoing computerized tomography (CT) scanning. RESULTS: We enroled 305 participants across nine sites. The statement "I have carefully considered what you told me about what brought you here today" was most frequently rated as important (88%). The statement "I have thought about the cost of your medical care to you today" was least frequently rated as important (59%). Participants preferred statements indicating physicians had considered their "vital signs and physical examination" (86%), "past medical history" (84%), and "what prior research tells me about your condition" (79%). Participants also valued statements conveying risks of testing, including potential kidney injury (78%) and radiation (77%). CONCLUSION: The majority of phrases were identified as important. Participants preferred statements conveying cognitive reassurance, medical knowledge and risks of testing. PRACTICE IMPLICATIONS: Our findings suggest specific phrases have the potential to enhance ED patient perceptions of physician empathy. Further research is needed to determine whether statements to convey empathy affect diagnostic testing rates.