Assessment of emergency medicine residents' computer knowledge and computer skills: time for an upgrade?

OBJECTIVE: To describe emergency medicine residents' (EMRs') personal computer (PC) use and educational needs and to compare their perceived and actual PC skills. METHODS: This was a prospective, cross-sectional study. Subjects were all EMRs at seven midwestern Accreditation Council for Graduate Medical Education (ACGME) residency programs. The EMRs completed a questionnaire about their PC use and ability to perform 23 tasks derived from two national retail-training programs. The tasks covered word processing, slide making, and Internet use. The EMRs then took a three-part test performing the skills in the questionnaire. Two independent raters scored the tests. Frequencies with 95% confidence intervals (95% CIs) were calculated for categorical data. Positive and negative predictive values were used to report information comparing residents' performance with their self-assessment of skills. Cohen's kappa was used to test agreement between raters. RESULTS: One hundred twenty-four of 158 (79%) eligible EMRs participated. Since not all participants engaged in all parts of the study, the sample size varies between 121 and 124. One hundred one of 122 (83%; 95% CI = 75 to 89) owned a PC. The EMRs use home PCs a mean of 3.8 hours/week for physician duties and use residency PCs 1.9 hours/week (range 0-20). Ninety-six of 122 (79%; 95% CI = 70 to 86) EMRs reported no formal PC training during residency. Thirty-five percent (43/122; 95% CI = 27 to 44) passed the word-processing test and 50% (62/123; 95% CI = 41 to 60) passed the slide-making test. Reasons for failure were because of errors and not having a presentable product. Thirty-eight of 122 (31%; 95% CI = 23 to 40) failed the literature search, including 33 who said they could perform it. One hundred fifteen of 123 (94%; 95% CI = 88 to 98) EMRs were able to find an Internet address, including ten who stated they could not. Twenty-one percent of the residents who attempted any test (26/124; 95% CI = 14 to 29) passed all three tests. There was no association between year of training and success on the tests (p = 0.374). Thirty-seven of 115 (32%; 95% CI = 24 to 42) EMRs said they had insufficient PC training to meet their physician needs. CONCLUSIONS: Emergency medicine residents have much access to computer technology and possess some computer skills; however, many are unable to produce a usable product or conduct a literature search. Emergency medicine residents have not had sufficient computer training prior to residency. The computer skills of EMRs should be assessed through skills testing rather than self-assessment, and computer training during residency should be improved.

Acute type a aortic dissection in a 36-week pregnant patient.

Aortic dissection is a relatively rare yet often fatal condition. Early recognition and treatment are crucial for survival. While the majority of patients who present with aortic dissection are older than 50 years of age and have a history of hypertension, younger patients with connective tissue disease, bicuspid aortic valves, and a family history of aortic dissection are also at an increased risk for developing this condition. A review of the literature revealed a paucity of published cases describing the successful, emergent repair of acute type A aortic dissections in third- trimester gravid patients. We present the case of the successful diagnosis and surgical repair of a 41-year-old female who presented to the emergency department with an acute type A aortic dissection at 36 weeks of gestation.

Technology-assisted education in graduate medical education: a review of the literature.

UNLABELLED: Studies on computer-aided instruction and web-based learning have left many questions unanswered about the most effective use of technology-assisted education in graduate medical education. OBJECTIVE: We conducted a review of the current medical literature to report the techniques, methods, frequency and effectiveness of technology-assisted education in graduate medical education. METHODS: A structured review of MEDLINE articles dealing with "Computer-Assisted Instruction," "Internet or World Wide Web," "Education" and "Medical" limited to articles published between 2002-2007 in the English language was performed. RESULTS: The two literature searches returned 679 articles; 184 met our inclusion and exclusion criteria. In 87 articles, effectiveness was measured primarily using self-reported results from a survey of subjects. Technology-assisted education was superior to traditional methods in 42 of the 64 direct comparison articles (66%, 95% CI 53-77%). Traditional teaching methods were superior to technology-assisted education in only 3/64 (5%, 95% CI 1-13%). The remaining 19 direct comparison articles showed no difference. A detailed review of the 64 comparative studies (technology-assisted education versus traditional teaching methods) also failed to identify a best method or best uses for technology-assisted education. CONCLUSIONS: Technology-assisted education is used in graduate medical education across a variety of content areas and participant types. Knowledge gain was the predominant outcome measured. The majority of studies that directly compared knowledge gains in technology-assisted education to traditional teaching methods found technology-assisted education equal or superior to traditional teaching methods, though no "best methods" or "best use" was found within those studies. Only three articles were specific to Emergency Medicine, suggesting further research in our specialty is warranted.

The use of ultrasound to identify pertinent landmarks for lumbar puncture.

OBJECTIVE: This study was conducted to assess the ultrasound's (US's) ability to identify pertinent landmarks for lumbar puncture (LP) in patients of various body mass indices (BMIs) and establish spatial relationships of pertinent LP landmarks across BMIs. METHODS: In this institutional review board-approved cross-sectional study, we calculated the BMIs of eligible patients and then categorized them as normal (BMI < or =24.9), overweight (BMI 24.9-30), or obese (BMI > or =30). We recorded the difficulty in palpating traditional LP landmarks. Identification and measurement of the spatial relationships of the sacrum; spinous processes of lumbar vertebrae L3, L4, and L5; ligamentum flavum; and the spinal canal by US was attempted. RESULTS: Successful identification of pertinent structures (L4-L5 spinous processes and the spinal canal) occurred in 100% of patients with normal BMI, 95% of those who were overweight, and 74% of those who were obese (P = .011). Difficulty in palpating landmarks was noted in 5% of patients with normal BMI, 33% of those who were overweight, and 68% of those who were obese (P < .0001). In subjects with difficult-to-palpate landmarks, US identified pertinent structures in 16 of 21 (76%; 95% confidence interval, 53-92). The average distance from skin to ligamentum flavum was 44 mm in those with normal BMI, 51 mm in those who were overweight, and 64 mm in those who were obese (P < .00001); measurements between spinous processes did not vary by BMI. Overall, there was a moderate correlation (0.62) between BMI and the distance from skin to ligamentum flavum. CONCLUSION: The usefulness of US in identifying structures for LP is inversely related to BMI. Even with this limitation, US is still able to identify obese patients' pertinent landmarks almost 75% of the time. In addition, US may be helpful in identifying pertinent structures for LP in those patients with difficult-to-palpate landmarks. In patients who were obese with structures not palpable by hand or identifiable by US, other modalities should be considered.

Development of a specialty-wide web-based medical knowledge assessment tool for resident education.

Medical knowledge is one of six core competencies identified by the Accreditation Council for Graduate Medical Education. The authors present a tool for assessment of medical knowledge developed by the Council of Emergency Medicine Residency Directors. This tool is Internet based and consists of more than 50 online tests that emergency medicine residents are able to access. Test results are available to a resident's residency, along with the mean and standard deviation of all takers of that particular test. The result is a collaborative specialty-wide approach to the common problem of formatting tests to assess medical knowledge. The tool has been widely accepted by both residents and residencies.

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.