The effect of clinical experience on the error rate of emergency physicians.

STUDY OBJECTIVE: We assess the effect of emergency physicians' clinical experience on the propensity to commit a patient care error. METHODS: Seven years of data from a single emergency department's peer review activities were reviewed for all patient care errors made by emergency physicians. Emergency physician clinical experience was defined as years since completion of residency training during the year each error was made. A repeated-measures log-linear model was constructed that predicted error count and the rate of errors over time, with a correction for number of patients treated by each physician. RESULTS: Of 829 cases reviewed during 7 years, there were 374 emergency physician errors identified. Mean emergency physician experience was 8.1+/-8.6 years. Emergency physicians with experience of 1.5 years or more were less likely to make an error (relative risk [RR]=0.66; 95% confidence interval [CI] 0.48 to 0.91) than those who were less experienced. Errors were not associated with emergency physician age (RR=1.01; 95% CI 0.99 to 1.03) or sex (RR=1.29; 95% CI 0.93 to 1.79). CONCLUSION: Emergency physicians with less than 1.5 years of clinical experience may be more likely to commit errors than more experienced emergency physicians.

A Novel Specialty-Specific, Collaborative Faculty Development Opportunity in Education Research: Program Evaluation at Five Years.

PURPOSE: For the busy clinician-educator, accessing opportunities that develop the skills and knowledge necessary to perform education research can be problematic. The Medical Education Research Certification at Council of Emergency Medicine Residency Directors (MERC at CORD) Scholars' Program is a potential alternative. The current study evaluates the program's outcomes after five years. METHOD: The authors employed a quasi-experimental design in this study. The study population consisted of the initial five MERC at CORD cohorts (2009-2013). Development of a logic model informed Kirkpatrick-level outcomes. Data from annual pre/post surveys, an alumni survey (2014), and tracking of national presentations/peer-reviewed publications resulting from program projects served as outcome measurements. RESULTS: Over the first five years, 149 physicians participated in the program; 97 have completed six MERC workshops, and 63 have authored a national presentation and 30 a peer-reviewed publication based on program projects. Of the 79 participants responding to the pre- and postsurveys from the 2011-2013 cohorts, 65 (82%) reported significant improvement in skills and knowledge related to education research and would recommend the program. Of the 61 graduates completing the alumni survey, 58 (95%) indicated their new knowledge was instrumental beyond educational research, including promotion to new leadership positions, and 28 (47% of the 60 responding) reported initiating a subsequent multi-institutional education study. Of these, 57% (16/28) collaborated with one or more peers/mentors from their original program project. CONCLUSIONS: Kirkpatrick-level outcomes 1, 2, 3, and perhaps 4 demonstrate that the MERC at CORD program is successful in its intended purpose.

The Development of Best Practice Recommendations to Support the Hiring, Recruitment, and Advancement of Women Physicians in Emergency Medicine.

BACKGROUND: Women in medicine continue to experience disparities in earnings, promotion, and leadership roles. There are few guidelines in place defining organization-level factors that promote a supportive workplace environment beneficial to women in emergency medicine (EM). We assembled a working group with the goal of developing specific and feasible recommendations to support women's professional development in both community and academic EM settings. METHODS: We formed a working group from the leadership of two EM women's organizations, the Academy of Women in Academic Emergency Medicine (AWAEM) and the American Association of Women Emergency Physicians (AAWEP). Through a literature search and discussion, working group members identified four domains where organizational policies and practices supportive of women were needed: 1) global approaches to supporting the recruitment, retention, and advancement of women in EM; 2) recruitment, hiring, and compensation of women emergency physicians; 3) supporting development and advancement of women in EM; and 4) physician health and wellness (in the context of pregnancy, childbirth, and maternity leave). Within each of these domains, the working group created an initial set of specific recommendations. The working group then recruited a stakeholder group of EM physician leaders across the country, selecting for diversity in practice setting, geographic location, age, race, and gender. Stakeholders were asked to score and provide feedback on each of the recommendations. Specific recommendations were retained by the working group if they achieved high rates of approval from the stakeholder group for importance and perceived feasibility. Those with >80% agreement on importance and >50% agreement on feasibility were retained. Finally, recommendations were posted in an open online forum (blog) and invited public commentary. RESULTS: An initial set of 29 potential recommendations was created by the working group. After stakeholder voting and feedback, 16 final recommendations were retained. Recommendations were refined through qualitative comments from stakeholders and blog respondents. CONCLUSIONS: Using a consensus building process that included male and female stakeholders from both academic and community EM settings, we developed recommendations for organizations to implement to create a workplace environment supportive of women in EM that were perceived as acceptable and feasible. This process may serve as a model for other medical specialties to establish clear, discrete organization-level practices aimed at supporting women physicians.

A survey to determine the prevalence and characteristics of training in Evidence-Based Medicine in emergency medicine residency programs.

We conducted a survey to determine the prevalence, training methods, and allotment of time for teaching evidence-based medicine (EBM) skills within accredited Emergency Medicine (EM) residency programs in the United States. A survey was mailed to program directors of all 122 accredited Emergency Medicine residency programs. The survey was also sent to program directors using an e-mail listserv. Responses were obtained from 53% of programs; 80% (95% CI: 68-89) of EM programs reported teaching some EBM. Although respondents believed a median of 10 hours were required to adequately cover this topic, only 22% provided more than 5 hours per year. Sixtey-three percent (95% CI: 50-75) of respondents reported using the JAMA Users' Guides series in journal club and 83% reported efforts to link journal clubs to patient care. Perceived barriers to integrating EBM into teaching and patient care included lack of trained faculty, lack of time, lack of familiarity with EBM resources, insufficient funding, and lack of interested faculty. In summary, academic EM programs are attempting to train residents in EBM, but perceive a lack of trained faculty, time, and funding as barriers. Desired resources include a defined curriculum, on-line training for faculty, and defined strategies for integration of EBM into training and patient care.

Faculty development: the educator's portfolio: its preparation, uses, and value in academic medicine.

The educator's portfolio is of value for both university and community-based academic faculty. It can be used to document scholarly activity and teaching and to prepare for periodic evaluations. Many faculty members use it to assist them in managing their careers and to reflect on activities and teaching efforts to ensure continued growth in competency as teachers. Promotion and tenure committees of many institutions now use this document to aid them in making promotion decisions.

Diagnostic errors.

One of the most complex and challenging tasks facing physicians is the need to make a diagnosis. Recent research has focused attention on medical errors alleged to have resulted in increased patient morbidity and mortality. A number of authorities have suggested methods to track and prevent errors. Most have dealt with systems' changes and fail-safe methods to prevent medication errors and commission of errors during treatment. Few have addressed methods to find and prevent diagnostic errors. Unless diagnostic error is either avoided or corrected early, fail-safe methods to prevent medication and treatment errors will ultimately fail to improve patient outcome. American medical literature, particularly postmortem studies, have documented diagnostic error since at least 1912. European literature shows the problem is worldwide. The limits of human memory and errors in both observation and processing of information during problem solving contribute to the commission of errors. The purpose of this article is to examine the thinking patterns and cognitive errors that can result in diagnostic error, and suggest instructional strategies that can be used to alert residents and attending physicians to these potential problems so they can be avoided.

Critical appraisal of emergency medicine education research: the best publications of 2013.

OBJECTIVES: The objective was to critically appraise and highlight methodologically superior medical education research articles published in 2013 whose outcomes are pertinent to teaching and education in emergency medicine (EM). METHODS: A search of the English-language literature in 2013 querying Education Resources Information Center (ERIC), PsychINFO, PubMed, and Scopus identified 251 EM-related studies using hypothesis-testing or observational investigations of educational interventions. Two reviewers independently screened all of the publications and removed articles using established exclusion criteria. Six reviewers then independently scored the remaining 43 publications using either a qualitative a or quantitative scoring system, based on the research methodology of each article. Each scoring system consisted of nine criteria. Selected criteria were based on accepted educational review literature and chosen a priori. Both scoring systems used parallel scoring metrics and have been used previously within this annual review. RESULTS: Forty-three medical education research papers (37 quantitative and six qualitative studies) met the a priori criteria for inclusion and were reviewed. Six quantitative and one qualitative study were scored and ranked most highly by the reviewers as exemplary and are summarized in this article. CONCLUSIONS: This annual critical appraisal article aims to promote superior research in EM-related education, by reviewing and highlighting seven of 43 major education research studies, meeting a priori criteria, and published in 2013. Common methodologic pitfalls in the 2013 papers are noted, and current trends in medical education research in EM are discussed.

Critical appraisal of emergency medicine educational research: the best publications of 2011.

OBJECTIVES: The objective was to critically appraise and highlight medical education research studies published in 2011 that were methodologically superior and whose outcomes were pertinent to teaching and education in emergency medicine (EM). METHODS: A search of the English language literature in 2011 querying PubMed, Scopus, Education Resources Information Center (ERIC), and PsychInfo identified EM studies that used hypothesis-testing or observational investigations of educational interventions. Six reviewers independently ranked all publications based on 10 criteria, including four related to methodology, that were chosen a priori to standardize evaluation by reviewers. This method was used previously to appraise medical education published in 2008, 2009, and 2010. RESULTS: Forty-eight educational research papers were identified. Comparing the literature of 2011 to that of 2008 through 2010, the number of published educational research papers meeting the criteria increased over time from 30, to 36, to 41, and now to 48. Five medical education research studies met the a priori criteria for inclusion as exemplary and are reviewed and summarized in this article. The number of funded studies remained fairly stable over the past 3 years, at 13 (2008), 16 (2009), 9 (2010), and 13 (2011). As in past years, research involving the use of technology accounted for almost half (n = 22) of the publications. Observational study designs accounted for 28 of the papers, while nine studies featured an experimental design. CONCLUSIONS: Forty-eight EM educational studies published in 2011 and meeting the criteria were identified. This critical appraisal reviews and highlights five studies that met a priori quality indicators. Current trends and common methodologic pitfalls in the 2011 papers are noted.

Critical appraisal of emergency medicine educational research: the best publications of 2010.

OBJECTIVES: The objective was to critically appraise and highlight medical education research studies published in 2010 that were methodologically superior and whose outcomes were pertinent to teaching and education in emergency medicine (EM). METHODS: A search of the English language literature in 2010 querying PubMed, Scopus, Education Resources Information Center (ERIC), and PsychInfo identified 41 EM studies that used hypothesis-testing or observational investigations of educational interventions. Five reviewers independently ranked all publications based on 10 criteria, including four related to methodology, that were chosen a priori to standardize evaluation by reviewers. This method was used previously to appraise medical education published in 2008 and 2009. RESULTS: Five medical education research studies met the a priori criteria for inclusion and are reviewed and summarized here. Comparing the literature of 2010 to 2008 and 2009, the number of published educational research papers increased from 30 to 36 and then to 41. The number of funded studies remained fairly stable over the past 3 years at 13 (2008), 16 (2009), and 9 (2010). As in past years, research involving the use of technology accounted for a significant number of publications (34%), including three of the five highlighted studies. CONCLUSIONS: Forty-one EM educational studies published in 2010 were identified. This critical appraisal reviews and highlights five studies that met a priori quality indicators. Current trends and common methodologic pitfalls in the 2010 papers are noted.

The CORD Academy for scholarship in education in emergency medicine.

In 2010 the Council of Emergency Medicine Residency Directors (CORD) established an Academy for Scholarship in Education in Emergency Medicine to define, promote, recognize, and reward excellence in education, education research, and education leadership in emergency medicine. In this article we describe the mission and aims of the Academy. Academies for medical educators are widespread in medical schools today and have produced many benefits both for faculty and for educational programs. Little effort, however, has been devoted to such a model in graduate medical education specialty societies. While CORD and other emergency medicine organizations have developed numerous initiatives to advance excellence in education, we believe that this effort will be accelerated if housed in the form of an Academy that emphasizes scholarship in teaching and other education activities. The CORD Academy for Scholarship in Education in Emergency Medicine is a new model for promoting excellence in education in graduate medical education specialty societies.

Critical appraisal of emergency medicine educational research: the best publications of 2009.

OBJECTIVES: The objective was to critically appraise and highlight methodologically superior medical education research specific to emergency medicine (EM) published in 2009. METHODS: A search of the English language literature in 2009 querying Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE 1950 to Present, Web of Science, Education Resources Information Center (ERIC), and PsychInfo identified 36 EM studies that used hypothesis-testing or observational investigations of educational interventions. Six reviewers independently ranked all publications based on 10 criteria, including four related to methodology, that were chosen a priori to standardize evaluation by reviewers. This was a refinement of the methods used to appraise medical education published in 2008. RESULTS: Seven studies met the standards as determined by the averaged rankings and are highlighted and summarized here. This year, 16 of 36 (44%) identified studies had funding, compared to 11 of 30 (36%) identified last year; five of seven (71%) highlighted publications were funded in 2009 compared to three of five (60%) highlighted in 2008. Use of technology in medical education was reported in 14 identified and four highlighted publications, with simulation being the most common technology studied. Five of the seven (71%) featured publications used a quasi-experimental or experimental design, one was observational, and one was qualitative. Practice management topics, including patient safety, efficiency, and revenue generation, were examined in seven reviewed studies. CONCLUSIONS: Thirty-six medical education publications published in 2009 focusing on EM were identified. This critical appraisal reviews and highlights seven studies that met a priori quality indicators. Current trends are noted.

Recommendations from the Society for Academic Emergency Medicine (SAEM) Taskforce on women in academic emergency medicine.

The Society for Academic Emergency Medicine (SAEM) convened a taskforce to study issues pertaining to women in academic emergency medicine (EM). The charge to the Taskforce was to "Create a document for the SAEM Board of Directors that defines and describes the unique recruitment, retention, and advancement needs for women in academic emergency medicine." To this end, the Taskforce and authors reviewed the literature to highlight key data points in understanding this issue and made recommendations for individuals at four levels of leadership and accountability: leadership of national EM organizations, medical school deans, department chairs, and individual women faculty members. The broad range of individuals targeted for recommendations reflects the interdependent and shared responsibility required to address changes in the culture of academic EM. The following method was used to determine the recommendations: 1) Taskforce members discussed career barriers and potential solutions that could improve the recruitment, retention, and advancement of women in academic EM; 2) the authors reviewed recommendations in the literature by national consensus groups and experts in the field to validate the recommendations of Taskforce members and the authors; and 3) final recommendations were sent to all Taskforce members to obtain and incorporate additional comments and ensure a consensus. This article contains those recommendations and cites the relevant literature addressing this topic.

Characteristics of emergency medicine program directors.

OBJECTIVES: To characterize emergency medicine (EM) program directors (PDs) and compare the data, where possible, with those from other related published studies. METHODS: An online survey was e-mailed in 2002 to all EM PDs of programs that were approved by the Accreditation Council of Graduate Medical Education. The survey included questions concerning demographics, work hours, support staff, potential problems and solutions, salary and expenses, and satisfaction. RESULTS: One hundred nine of 124 (88%) PDs (69.7% university, 27.5% community, and 2.8% military) completed the survey; 85.3% were male. Mean age was 43.6 years (95% confidence interval [CI] = 42.6 to 44.7 yr). The mean time as a PD was 5.7 years (95% CI = 4.9 to 6.5 yr), with 56% serving five years or less. The mean time expected to remain as PD is an additional 6.0 years (95% CI = 5.2 to 6.8). A 1995 study noted that 50% of EM PDs had been in the position for less than three years, and 68% anticipated continuing in their position for less than five years. On a scale of 1 to 10 (with 10 as highest), the mean satisfaction with the position of PD was 8.0 (95% CI = 7.2 to 8.3). Those PDs who stated that the previous PD had mentored them planned to stay a mean of 2.0 years longer than did those who were not mentored (95% CI of difference of means = 0.53 to 3.53). Sixty-five percent of PDs had served previously as an associate PD. Most PDs (92%) have an associate or assistant PD, with 54% reporting one; 25%, two; and 9%, three associate or assistant PDs. A 1995 study noted that 62% had an associate PD. Ninety-two percent have a program coordinator, and 35% stated that they have both a residency secretary and a program coordinator. Program directors worked a median of 195 hours per month: clinical, 75 hours; scholarly activity, 20 hours; administrative, 80 hours; and teaching and residency conferences, 20 hours; compared with a median total hours of 220 previously reported. Lack of adequate time to do the job required, career needs interfering with family needs, and lack of adequate faculty help with residency matters were identified as the most important problems (means of 3.5 [95% CI = 3.2 to 3.7], 3.4 [95% CI = 3.2 to 3.6], and 3.1 [95% CI = 2.9 to 3.3], respectively, on a scale of 1 to 5, with 5 as maximum). This study identified multiple resources that were found to be useful by >50% of PDs, including national meetings, lectures, advice from others, and self-study. CONCLUSIONS: Emergency medicine PDs generally are very satisfied with the position of PD, perhaps because of increased support and resources. Although PD turnover remains an issue, PDs intend to remain in the position for a longer period of time than noted before this study. This may reflect the overall satisfaction with the position as well as the increased resources and support now available to the PD. PDs have greater satisfaction if they have been mentored for the position.