Carl Preiksaitis MD, Christopher Nash MD, EdM, Michael Gottlieb MD, Teresa M. Chan MD, MHPE, Al'ai Alvarez MD, Adaira Landry MD
Objectives
Letters of recommendation (LORs) are essential within academic medicine, affecting a number of important decisions regarding advancement, yet these letters take significant amounts of time and labor to prepare. The use of generative artificial intelligence (AI) tools, such as ChatGPT, are gaining popularity for a variety of academic writing tasks and offer an innovative solution to relieve the burden of letter writing. It is yet to be determined if ChatGPT could aid in crafting LORs, particularly in high-stakes contexts like faculty promotion. To determine the feasibility of this process and whether there is a significant difference between AI and human-authored letters, we conducted a study aimed at determining whether academic physicians can distinguish between the two.
Methods
A quasi-experimental study was conducted using a single-blind design. Academic physicians with experience in reviewing LORs were presented with LORs for promotion to associate professor, written by either humans or AI. Participants reviewed LORs and identified the authorship. Statistical analysis was performed to determine accuracy in distinguishing between human and AI-authored LORs. Additionally, the perceived quality and persuasiveness of the LORs were compared based on suspected and actual authorship.
Results
A total of 32 participants completed letter review. The mean accuracy of distinguishing between human- versus AI-authored LORs was 59.4%. The reviewer's certainty and time spent deliberating did not significantly impact accuracy. LORs suspected to be human-authored were rated more favorably in terms of quality and persuasiveness. A difference in gender-biased language was observed in our letters: human-authored letters contained significantly more female-associated words, while the majority of AI-authored letters tended to use more male-associated words.
Conclusions
Participants were unable to reliably differentiate between human- and AI-authored LORs for promotion. AI may be able to generate LORs and relieve the burden of letter writing for academicians. New strategies, policies, and guidelines are needed to balance the benefits of AI while preserving integrity and fairness in academic promotion decisions.
{"title":"Brain versus bot: Distinguishing letters of recommendation authored by humans compared with artificial intelligence","authors":"Carl Preiksaitis MD, Christopher Nash MD, EdM, Michael Gottlieb MD, Teresa M. Chan MD, MHPE, Al'ai Alvarez MD, Adaira Landry MD","doi":"10.1002/aet2.10924","DOIUrl":"https://doi.org/10.1002/aet2.10924","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>Letters of recommendation (LORs) are essential within academic medicine, affecting a number of important decisions regarding advancement, yet these letters take significant amounts of time and labor to prepare. The use of generative artificial intelligence (AI) tools, such as ChatGPT, are gaining popularity for a variety of academic writing tasks and offer an innovative solution to relieve the burden of letter writing. It is yet to be determined if ChatGPT could aid in crafting LORs, particularly in high-stakes contexts like faculty promotion. To determine the feasibility of this process and whether there is a significant difference between AI and human-authored letters, we conducted a study aimed at determining whether academic physicians can distinguish between the two.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>A quasi-experimental study was conducted using a single-blind design. Academic physicians with experience in reviewing LORs were presented with LORs for promotion to associate professor, written by either humans or AI. Participants reviewed LORs and identified the authorship. Statistical analysis was performed to determine accuracy in distinguishing between human and AI-authored LORs. Additionally, the perceived quality and persuasiveness of the LORs were compared based on suspected and actual authorship.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 32 participants completed letter review. The mean accuracy of distinguishing between human- versus AI-authored LORs was 59.4%. The reviewer's certainty and time spent deliberating did not significantly impact accuracy. LORs suspected to be human-authored were rated more favorably in terms of quality and persuasiveness. A difference in gender-biased language was observed in our letters: human-authored letters contained significantly more female-associated words, while the majority of AI-authored letters tended to use more male-associated words.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Participants were unable to reliably differentiate between human- and AI-authored LORs for promotion. AI may be able to generate LORs and relieve the burden of letter writing for academicians. New strategies, policies, and guidelines are needed to balance the benefits of AI while preserving integrity and fairness in academic promotion decisions.</p>\u0000 </section>\u0000 </div>","PeriodicalId":37032,"journal":{"name":"AEM Education and Training","volume":null,"pages":null},"PeriodicalIF":1.8,"publicationDate":"2023-11-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/aet2.10924","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138468422","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Brandon Haefke MD, Daniel Scholz MD, James (Jim) Homme MD, Derick Jones MD
Introduction
Many emergency medicine (EM) residency programs include clinical rotations in rural emergency departments (“rural rotations”) as part of their curriculum. These rotations are designed to expose residents to clinical scenarios that are less frequently encountered in tertiary centers. The objective of this study was to determine the rate at which residents were exposed to certain clinical and procedural experiences (CPEs) while on rural rotations compared to their usual academic training hospital.
Methods
We conducted a retrospective chart review of all patient encounters involving EM residents at a large academic hospital in Rochester, Minnesota, compared with two rural hospitals in Austin, Minnesota, and Albert Lea, Minnesota, from July 1, 2019, to June 30, 2020. The frequency of each CPE was calculated and expressed as the number of CPEs encountered per 100 clinical hours worked. These values were compared between the rural and academic sites.
Results
A total of 33,417 patient encounters over a total of 41,700 resident clinical hours were analyzed between the three study sites. The two settings (rural vs. academic) had significant differences in baseline patient demographics including age, acuity, and admission rates. Several CPEs were found to occur at a higher frequency in the rural hospitals versus the academic hospital: ambulance necessity documentation (9.3/100 h rural vs. 0.07/100 h academic, p ≤ 0.0001), laceration repair (3.39/100 h rural vs. 2.0/100 h academic, p = 0.0004), and splint/cast application (1.53/100 h rural vs. 0.07/100 h academic, p ≤ 0.0001).
Conclusions
Rural EM rotations provide residents exposure to a variety of valuable educational experiences. These rotations may provide residents with superior exposures to some clinical experiences compared to academic hospitals, particularly out-of-ED transfers and orthopedic procedures. Residency programs without a current rural rotation should consider creating this as an option for their trainees.
{"title":"Defining the clinical and procedural opportunities available to residents during rural rotations","authors":"Brandon Haefke MD, Daniel Scholz MD, James (Jim) Homme MD, Derick Jones MD","doi":"10.1002/aet2.10922","DOIUrl":"https://doi.org/10.1002/aet2.10922","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>Many emergency medicine (EM) residency programs include clinical rotations in rural emergency departments (“rural rotations”) as part of their curriculum. These rotations are designed to expose residents to clinical scenarios that are less frequently encountered in tertiary centers. The objective of this study was to determine the rate at which residents were exposed to certain clinical and procedural experiences (CPEs) while on rural rotations compared to their usual academic training hospital.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We conducted a retrospective chart review of all patient encounters involving EM residents at a large academic hospital in Rochester, Minnesota, compared with two rural hospitals in Austin, Minnesota, and Albert Lea, Minnesota, from July 1, 2019, to June 30, 2020. The frequency of each CPE was calculated and expressed as the number of CPEs encountered per 100 clinical hours worked. These values were compared between the rural and academic sites.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 33,417 patient encounters over a total of 41,700 resident clinical hours were analyzed between the three study sites. The two settings (rural vs. academic) had significant differences in baseline patient demographics including age, acuity, and admission rates. Several CPEs were found to occur at a higher frequency in the rural hospitals versus the academic hospital: ambulance necessity documentation (9.3/100 h rural vs. 0.07/100 h academic, <i>p</i> ≤ 0.0001), laceration repair (3.39/100 h rural vs. 2.0/100 h academic, <i>p</i> = 0.0004), and splint/cast application (1.53/100 h rural vs. 0.07/100 h academic, <i>p</i> ≤ 0.0001).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Rural EM rotations provide residents exposure to a variety of valuable educational experiences. These rotations may provide residents with superior exposures to some clinical experiences compared to academic hospitals, particularly out-of-ED transfers and orthopedic procedures. Residency programs without a current rural rotation should consider creating this as an option for their trainees.</p>\u0000 </section>\u0000 </div>","PeriodicalId":37032,"journal":{"name":"AEM Education and Training","volume":null,"pages":null},"PeriodicalIF":1.8,"publicationDate":"2023-11-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138468402","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Snimarjot Kaur MBBS, William Lynders MD, Michael Goldman MD, Christie Bruno MD, Juliana Morin MSN, RN, Scott Maruschock, Marc Auerbach MD, MSci
Background
Gaps in quality of pediatric emergency care have been noted in community emergency departments (CEDs), where >85% of children receive care. In situ simulation provides opportunities for hands-on experiences and can help close these gaps. We aimed to develop, implement, and evaluate an innovative, replicable, and scalable pediatric in situ simulation-based CED curriculum, under the leadership of a local colleague, through collaborative approach with a regional academic medical center (AMC).
Methods
Kern's model was used as follows: problem identification and general needs assessment—pediatric readiness assessment and discussions with CED physician and nursing leadership; targeted needs assessment—review of recent pediatric transfer cases; goals and objectives—enhance pediatric knowledge and skills of interprofessional teams and detect latent safety threats; educational strategies—codeveloped by CED and AMC, included prelearning using podcasts and videos, simulation and facilitated debriefing, resource sharing after simulations; implementation—3-h simulation sessions facilitated in person by the CED team and remotely by AMC (leadership required participation and paid staff); and evaluation and feedback—retrospective pre–post survey, Simulation Effectiveness Tool–Modified (SET-M), Net Promoter Score (NPS), and review/feedback meetings.
Results
Based on needs assessment, the selected cases included newborn resuscitation, seizure, asthma, and tetrahydrocannabinol ingestion causing altered mental sensorium in a child. Twenty-four 3-h simulation sessions were conducted over 1 year. A total of 168 participants completed the sessions, while 75 participants (54.7% nurses, 22.7% physicians, and others) completed feedback surveys. Seventy-six percent of participants reported completing presimulation education material. Participants reported improved skills at appropriately evaluating a critically ill newborn and critically ill infant/toddler and improved teamwork during the care of a pediatric patient. The majority agreed that simulation was effective in teaching pediatric resuscitation. The NPS was 84% (excellent).
Conclusions
A locally facilitated CED in situ simulation curriculum was successfully developed and implemented under local leadership, with remote collaboration by AMC. The curriculum was well received and effective.
{"title":"Blueprint for community emergency department pediatric simulation","authors":"Snimarjot Kaur MBBS, William Lynders MD, Michael Goldman MD, Christie Bruno MD, Juliana Morin MSN, RN, Scott Maruschock, Marc Auerbach MD, MSci","doi":"10.1002/aet2.10925","DOIUrl":"https://doi.org/10.1002/aet2.10925","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Gaps in quality of pediatric emergency care have been noted in community emergency departments (CEDs), where >85% of children receive care. In situ simulation provides opportunities for hands-on experiences and can help close these gaps. We aimed to develop, implement, and evaluate an innovative, replicable, and scalable pediatric in situ simulation-based CED curriculum, under the leadership of a local colleague, through collaborative approach with a regional academic medical center (AMC).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Kern's model was used as follows: <i>problem identification and general needs assessment</i>—pediatric readiness assessment and discussions with CED physician and nursing leadership; <i>targeted needs assessment</i>—review of recent pediatric transfer cases; <i>goals and objectives</i>—enhance pediatric knowledge and skills of interprofessional teams and detect latent safety threats; <i>educational strategies</i>—codeveloped by CED and AMC, included prelearning using podcasts and videos, simulation and facilitated debriefing, resource sharing after simulations; <i>implementation</i>—3-h simulation sessions facilitated in person by the CED team and remotely by AMC (leadership required participation and paid staff); and <i>evaluation and feedback</i>—retrospective pre–post survey, Simulation Effectiveness Tool–Modified (SET-M), Net Promoter Score (NPS), and review/feedback meetings.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Based on needs assessment, the selected cases included newborn resuscitation, seizure, asthma, and tetrahydrocannabinol ingestion causing altered mental sensorium in a child. Twenty-four 3-h simulation sessions were conducted over 1 year. A total of 168 participants completed the sessions, while 75 participants (54.7% nurses, 22.7% physicians, and others) completed feedback surveys. Seventy-six percent of participants reported completing presimulation education material. Participants reported improved skills at appropriately evaluating a critically ill newborn and critically ill infant/toddler and improved teamwork during the care of a pediatric patient. The majority agreed that simulation was effective in teaching pediatric resuscitation. The NPS was 84% (excellent).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>A locally facilitated CED in situ simulation curriculum was successfully developed and implemented under local leadership, with remote collaboration by AMC. The curriculum was well received and effective.</p>\u0000 </section>\u0000 </div>","PeriodicalId":37032,"journal":{"name":"AEM Education and Training","volume":null,"pages":null},"PeriodicalIF":1.8,"publicationDate":"2023-11-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138468421","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Secondary outcomes","authors":"Matthew R. Klein MD, MPH","doi":"10.1002/aet2.10923","DOIUrl":"https://doi.org/10.1002/aet2.10923","url":null,"abstract":"","PeriodicalId":37032,"journal":{"name":"AEM Education and Training","volume":null,"pages":null},"PeriodicalIF":1.8,"publicationDate":"2023-11-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138468403","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kyle Schoppel MD, Jordan Spector MD, Ijeoma Okafor MPH, Richard Church MD, Katy Deblois DO, David Della-Giustina MD, Adam Kellogg MD, Casey MacVane MD, PMH, Matthew Pirotte MD, David Snow MD, Geoffrey Hays MD, Amy Mariorenzi MD, Haley Connelly, Alexander Sheng MD
Background
More than 90% of pediatric patients presenting to emergency departments (EDs) in the United States are evaluated and treated in community-based EDs. Recent evidence suggests that mortality outcomes may be worse for critically ill pediatric patients treated at community EDs. The disparate mortality outcomes may be due to inconsistency in pediatric-specific education provided to emergency medicine (EM) trainees during residency training. There are few studies surveying recently graduated EM physicians assessing perceived gaps in the pediatric emergency medicine (PEM) education they received during residency.
Methods
This was a prospective, survey-based, descriptive cohort study of EM residency graduates from 10 institutions across the United States who were <5 years out from residency training. Deidentified surveys were distributed via email.
Results
A total of 222 responses were obtained from 570 eligible participants (39.1%). Non-ED pediatric rotations during residency training included pediatric intensive care (60%), pediatric anesthesia (32.4%), neonatal intensive care unit (26.1%), and pediatric wards (17.1%). A large percentage (42.8%) of respondents felt uncomfortable managing neonates and performing tube thoracostomy on pediatric patients (56.3%). The EM graduate's satisfaction with pediatric simulation–based training during residency was positively associated with comfort caring for neonates and infants (p < 0.0070 and p < 0.0002) and performing endotracheal intubation (p < 0.0027), lumbar puncture (p < 0.0004), and Pediatric Advanced Life Support resuscitation (p < 0.0001).
Conclusions/discussion
This survey-based cohort study found considerable variation in pediatric-specific experiences during EM residency training and in perceived comfort managing pediatric patients. In general, participants were more comfortable managing older children. This study suggests that the greatest perceived knowledge gaps in PEM were neonatal medicine/resuscitation and pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the United States to promote future educational initiatives.
{"title":"Gaps in pediatric emergency medicine education of emergency medicine residents: A needs assessment of recent graduates","authors":"Kyle Schoppel MD, Jordan Spector MD, Ijeoma Okafor MPH, Richard Church MD, Katy Deblois DO, David Della-Giustina MD, Adam Kellogg MD, Casey MacVane MD, PMH, Matthew Pirotte MD, David Snow MD, Geoffrey Hays MD, Amy Mariorenzi MD, Haley Connelly, Alexander Sheng MD","doi":"10.1002/aet2.10918","DOIUrl":"https://doi.org/10.1002/aet2.10918","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>More than 90% of pediatric patients presenting to emergency departments (EDs) in the United States are evaluated and treated in community-based EDs. Recent evidence suggests that mortality outcomes may be worse for critically ill pediatric patients treated at community EDs. The disparate mortality outcomes may be due to inconsistency in pediatric-specific education provided to emergency medicine (EM) trainees during residency training. There are few studies surveying recently graduated EM physicians assessing perceived gaps in the pediatric emergency medicine (PEM) education they received during residency.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This was a prospective, survey-based, descriptive cohort study of EM residency graduates from 10 institutions across the United States who were <5 years out from residency training. Deidentified surveys were distributed via email.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>A total of 222 responses were obtained from 570 eligible participants (39.1%). Non-ED pediatric rotations during residency training included pediatric intensive care (60%), pediatric anesthesia (32.4%), neonatal intensive care unit (26.1%), and pediatric wards (17.1%). A large percentage (42.8%) of respondents felt uncomfortable managing neonates and performing tube thoracostomy on pediatric patients (56.3%). The EM graduate's satisfaction with pediatric simulation–based training during residency was positively associated with comfort caring for neonates and infants (<i>p</i> < 0.0070 and <i>p</i> < 0.0002) and performing endotracheal intubation (<i>p</i> < 0.0027), lumbar puncture (<i>p</i> < 0.0004), and Pediatric Advanced Life Support resuscitation (<i>p</i> < 0.0001).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions/discussion</h3>\u0000 \u0000 <p>This survey-based cohort study found considerable variation in pediatric-specific experiences during EM residency training and in perceived comfort managing pediatric patients. In general, participants were more comfortable managing older children. This study suggests that the greatest perceived knowledge gaps in PEM were neonatal medicine/resuscitation and pediatric cardiac arrest. Future research will continue to address larger cohorts, representative of the PEM education provided to EM physicians in the United States to promote future educational initiatives.</p>\u0000 </section>\u0000 </div>","PeriodicalId":37032,"journal":{"name":"AEM Education and Training","volume":null,"pages":null},"PeriodicalIF":1.8,"publicationDate":"2023-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138454723","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Michelle I. Suh MD, Carl Preiksaitis MD, Esther Chen MD
“So, how many of these have you done before?” As supervising attendings, we often ask this question to the resident setting up for a procedure as we decide whether to grab our own set of sterile gloves. Yet, this question assumes that the number of times someone has performed a procedure reflects their comfort, knowledge, and skill in performing that procedure. As academic physicians tasked with training competent emergency physicians, we need to set a higher bar for procedural skill attainment. While case numbers may help with skill attainment, procedural practice with performance feedback and assessment are critical to helping the novice achieve procedural proficiency and becoming an expert.1 Already adopted by surgical specialties, proficiency-based skills training represents a fundamental shift from quantity to quality. This requires establishing a proficiency criterion, providing objective and timely feedback to a trainee, and assessing a trainee's readiness for independent practice.2 Patient safety depends on our ability as emergency physicians to be procedurally proficient to provide skilled, competent care.
Procedural experience during emergency medicine (EM) training has primarily focused on procedural numbers across program types or trends in numbers over time.3, 4 During residency, trainees’ procedural skills are assessed biannually (Patient Care 8 of the EM Milestones) and case volume is measured as mandated by the EM Residency Review Committee.5, 6 A critical part of the EM resident portfolio, procedural logs satisfy the minimum procedural counts required by the EM Residency Review Committee.6 In this issue, Turner et al.7 questioned the adequacy of a minimum standard and highlighted the variability in trainee attempts needed to achieve proficiency in simulated cricothyrotomy, as measured by time to successful tracheal tube placement. Even though programs are required to measure their residents’ procedural milestones biannually,3 the approach by Turner et al. to procedural assessment is probably more than what most EM programs do in procedural assessment. However, is this sufficient to ensure procedural proficiency?
Developing proficiency in a procedure requires two things: (1) nontechnical skills, such as knowledge of procedural indications and complications, and (2) technical skills, often referred to as microsteps. However, we cannot know what we do not measure, and case logs only measure the number of cases done. Logging a pericardiocentesis performed in simulation lab does not necessarily mean that the resident is able to understand the indications for the procedure, how to set up for the procedure, or even if they can perform the procedure successfully a year later. Exposure as a proxy for learning dates back to Osler's natural method of teachin
{"title":"Beyond the numbers: Reimagining procedural proficiency in emergency medicine residencies","authors":"Michelle I. Suh MD, Carl Preiksaitis MD, Esther Chen MD","doi":"10.1002/aet2.10920","DOIUrl":"https://doi.org/10.1002/aet2.10920","url":null,"abstract":"<p>“So, how many of these have you done before?” As supervising attendings, we often ask this question to the resident setting up for a procedure as we decide whether to grab our own set of sterile gloves. Yet, this question assumes that the number of times someone has performed a procedure reflects their comfort, knowledge, and skill in performing that procedure. As academic physicians tasked with training competent emergency physicians, we need to set a higher bar for procedural skill attainment. While case numbers may help with skill attainment, procedural practice with performance feedback and assessment are critical to helping the novice achieve procedural proficiency and becoming an expert.<span><sup>1</sup></span> Already adopted by surgical specialties, proficiency-based skills training represents a fundamental shift from quantity to quality. This requires establishing a proficiency criterion, providing objective and timely feedback to a trainee, and assessing a trainee's readiness for independent practice.<span><sup>2</sup></span> Patient safety depends on our ability as emergency physicians to be procedurally proficient to provide skilled, competent care.</p><p>Procedural experience during emergency medicine (EM) training has primarily focused on procedural numbers across program types or trends in numbers over time.<span><sup>3, 4</sup></span> During residency, trainees’ procedural skills are assessed biannually (Patient Care 8 of the EM Milestones) and case volume is measured as mandated by the EM Residency Review Committee.<span><sup>5, 6</sup></span> A critical part of the EM resident portfolio, procedural logs satisfy the minimum procedural counts required by the EM Residency Review Committee.<span><sup>6</sup></span> In this issue, Turner et al.<span><sup>7</sup></span> questioned the adequacy of a minimum standard and highlighted the variability in trainee attempts needed to achieve proficiency in simulated cricothyrotomy, as measured by time to successful tracheal tube placement. Even though programs are required to measure their residents’ procedural milestones biannually,<span><sup>3</sup></span> the approach by Turner et al. to procedural assessment is probably more than what most EM programs do in procedural assessment. However, is this sufficient to ensure procedural proficiency?</p><p>Developing proficiency in a procedure requires two things: (1) nontechnical skills, such as knowledge of procedural indications and complications, and (2) technical skills, often referred to as microsteps. However, we cannot know what we do not measure, and case logs only measure the number of cases done. Logging a pericardiocentesis performed in simulation lab does not necessarily mean that the resident is able to understand the indications for the procedure, how to set up for the procedure, or even if they can perform the procedure successfully a year later. Exposure as a proxy for learning dates back to Osler's <i>natural method of teachin","PeriodicalId":37032,"journal":{"name":"AEM Education and Training","volume":null,"pages":null},"PeriodicalIF":1.8,"publicationDate":"2023-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/aet2.10920","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138454722","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Mitchell C. Veverka MD, MS, Caitlin R. Ryus MD, MPH, Charles J. Gerardo MD, Steven L. Bernstein MD, Alexander J. Limkakeng MD, MHS
Emergency physicians (EPs) are well positioned to perform medical research. EPs are exposed to a wide range of disease types, medical specialties, and treatment modalities. Furthermore, emergency medicine (EM) serves as the safety net for the U.S. health care system. The diverse exposure provides a vast opportunity for EP to perform many worthwhile research projects. Yet, EM has historically had the lowest amount of funding and a lower number of National Institutes of Health–funded research projects. Many suggest the etiology is a “leaky” educational pipeline with loss of many potential physician-scientists over the training and development course. Current research training options for the EM physician-scientist includes MD-PhD, 4-year EM residency program and postresidency fellowships. While each has its advantages and disadvantages, we describe an additional educational alternative of EM physician-scientists, which we have named the integrated–dedicated research period within an EM residency. We describe the features of these programs and preliminary results from the graduates and current trainees.
{"title":"Fixing the leaky physician-scientist pipeline: Integrated–dedicated research period programs in emergency medicine","authors":"Mitchell C. Veverka MD, MS, Caitlin R. Ryus MD, MPH, Charles J. Gerardo MD, Steven L. Bernstein MD, Alexander J. Limkakeng MD, MHS","doi":"10.1002/aet2.10919","DOIUrl":"https://doi.org/10.1002/aet2.10919","url":null,"abstract":"<p>Emergency physicians (EPs) are well positioned to perform medical research. EPs are exposed to a wide range of disease types, medical specialties, and treatment modalities. Furthermore, emergency medicine (EM) serves as the safety net for the U.S. health care system. The diverse exposure provides a vast opportunity for EP to perform many worthwhile research projects. Yet, EM has historically had the lowest amount of funding and a lower number of National Institutes of Health–funded research projects. Many suggest the etiology is a “leaky” educational pipeline with loss of many potential physician-scientists over the training and development course. Current research training options for the EM physician-scientist includes MD-PhD, 4-year EM residency program and postresidency fellowships. While each has its advantages and disadvantages, we describe an additional educational alternative of EM physician-scientists, which we have named the integrated–dedicated research period within an EM residency. We describe the features of these programs and preliminary results from the graduates and current trainees.</p>","PeriodicalId":37032,"journal":{"name":"AEM Education and Training","volume":null,"pages":null},"PeriodicalIF":1.8,"publicationDate":"2023-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138454721","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sarah Edwards MSc(PEM), MSc(MedEd), Lakshman Swamy MD, MBA, Michael Cosimini MD, Bjorn Watsjold MD, MPH, Teresa M. Chan MD, MHPE, MBA
Abstract Serious games are an emerging tool for teaching and learning within medical education. These games can be used to facilitate learning or to demonstrate complex concepts in short bursts of interactive learning. This educator's blueprint will provide 10 strategies for creating a serious game, focusing on card and board games. These strategies include creating a project charter; determining the nature of the game; establishing game mechanics; selecting the best medium; prototyping and playtesting; reviewing sensitivity to equity, diversity, and inclusion; reviewing and refining content; funding game development, manufacture, and distribution; marketing and publicizing the game; and future‐proofing the game. This blueprint hopes to help aspiring serious game designers and educators to conceptualize the steps for successfully creating a new serious game for medical education.
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Sally A. Santen MD, PhD, Robin R. Hemphill MD, MPH, Martin Pusic MD, PhD, Stephen John Cico MD, MEd, Meg Wolff MD, MHPE, Chris Merritt MD, MHPE
On March 30, 1981, after President Reagan was shot in the chest by John Hinckley, he was taken to the hospital and required a chest tube. Rumor has it, a department chair stepped up to perform the procedure, hitting the intercostal artery in the process, necessitating a blood transfusion. As well-trained interns know, you place a chest tube above the rib; when you go below the rib, you may hit the intercostal artery. Although, this story may be urban legend, it resonates because it speaks to an important lesson—if you need a procedure, you want the person who does it the most frequently—the senior resident, junior attending, or specialized consultant. Most likely you do not want the department chair, associate dean, physician-scientist, part-time physician moving to retirement, or others with less clinical practice. Medical errors are common. Procedural complications are an important cause of adverse events, resulting in patient discomfort, longer hospital stays, and higher costs.1 These complications result in nearly 10% of hospital-wide adverse events; nearly half are considered preventable.2
For the past several years, our emergency medicine (EM) clinical practice has been about 20% of our time, less than 1 day a week. While we may be reluctant to admit it, the last lumbar puncture any of us performed was over a year ago, our last intubation was perhaps years ago, and a cricothyrotomy was in residency over 25 years ago. We practice in teaching hospitals, and have supervised these procedures, but have not recently performed them. While we believe that we are in equipoise, providing excellent patient care based on years of experience and balancing infrequent procedural performance, could we still do these procedures? Probably yes, maybe not perfectly, and at what risk to the patient? Yet, we still practice, and we accept the responsibility to provide optimal care for our patients. Moreover, our identity as competent emergency physicians is important and contributes to our professional credibility.
Emergency physicians have a continuous responsibility to maintain competency. Yet medical care is rapidly changing; new procedures such as ultrasound-guided nerve blocks become standard of care. There are new diseases such as COVID and new treatments such as thrombectomy for stroke. Further, about half of patients' medications did not exist in medical school and may not know the interactions and side effects. In addition, there are numerous high-acuity low opportunity (HALO) procedures (e.g., thoracotomy, lateral canthotomy, and transvenous pacer)3 and HALO patient presentations (e.g., neonatal shock, thyroid storm). So how do EM physicians maintain their knowledge and competencies, much less extend these into emerging procedures, medications, diseases, and treatments?
Maintenance of skills is important; crucial questions remain unanswered. What must EM phys
{"title":"Our responsibility to patients: Maintain competency or … stop practicing","authors":"Sally A. Santen MD, PhD, Robin R. Hemphill MD, MPH, Martin Pusic MD, PhD, Stephen John Cico MD, MEd, Meg Wolff MD, MHPE, Chris Merritt MD, MHPE","doi":"10.1002/aet2.10916","DOIUrl":"10.1002/aet2.10916","url":null,"abstract":"<p>On March 30, 1981, after President Reagan was shot in the chest by John Hinckley, he was taken to the hospital and required a chest tube. Rumor has it, a department chair stepped up to perform the procedure, hitting the intercostal artery in the process, necessitating a blood transfusion. As well-trained interns know, you place a chest tube above the rib; when you go below the rib, you may hit the intercostal artery. Although, this story may be urban legend, it resonates because it speaks to an important lesson—if you need a procedure, you want the person who does it the most frequently—the senior resident, junior attending, or specialized consultant. Most likely you do not want the department chair, associate dean, physician-scientist, part-time physician moving to retirement, or others with less clinical practice. Medical errors are common. Procedural complications are an important cause of adverse events, resulting in patient discomfort, longer hospital stays, and higher costs.<span><sup>1</sup></span> These complications result in nearly 10% of hospital-wide adverse events; nearly half are considered preventable.<span><sup>2</sup></span></p><p>For the past several years, our emergency medicine (EM) clinical practice has been about 20% of our time, less than 1 day a week. While we may be reluctant to admit it, the last lumbar puncture any of us performed was over a year ago, our last intubation was perhaps years ago, and a cricothyrotomy was in residency over 25 years ago. We practice in teaching hospitals, and have supervised these procedures, but have not recently performed them. While we believe that we are in equipoise, providing excellent patient care based on years of experience and balancing infrequent procedural performance, could we still do these procedures? Probably yes, maybe not perfectly, and at what risk to the patient? Yet, we still practice, and we accept the responsibility to provide optimal care for our patients. Moreover, our identity as competent emergency physicians is important and contributes to our professional credibility.</p><p>Emergency physicians have a continuous responsibility to maintain competency. Yet medical care is rapidly changing; new procedures such as ultrasound-guided nerve blocks become standard of care. There are new diseases such as COVID and new treatments such as thrombectomy for stroke. Further, about half of patients' medications did not exist in medical school and may not know the interactions and side effects. In addition, there are numerous high-acuity low opportunity (HALO) procedures (e.g., thoracotomy, lateral canthotomy, and transvenous pacer)<span><sup>3</sup></span> and HALO patient presentations (e.g., neonatal shock, thyroid storm). So how do EM physicians maintain their knowledge and competencies, much less extend these into emerging procedures, medications, diseases, and treatments?</p><p>Maintenance of skills is important; crucial questions remain unanswered. <i>What must EM phys","PeriodicalId":37032,"journal":{"name":"AEM Education and Training","volume":null,"pages":null},"PeriodicalIF":1.8,"publicationDate":"2023-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10664403/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138300287","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jabeen Fayyaz MBBS, MHPE, PhD, Margret Jaeger MPhil, Prisca Takundwa MD, Ammarah U. Iqbal MD, Adeel Khatri MBBS, Saima Ali MBBS, MHPE, Sama Mukhtar MBBS, Syed Ghazanfar Saleem MBBS, Travis Whitfill MPH, MACE, MPhil, Inayat Ali MSc, MPhil, PhD, Jonathan P. Duff MD, MEd, Suzan (Suzie) Kardong-Edgren PhD, Isabel Theresia Gross MD, PhD, MPH
Background
Cultural sensitivity (CS) training is vital to pediatric emergency medicine (PEM) curricula. This study aimed to explore CS in Yale PEM fellows and emergency medicine (EM) residents at Indus Hospital and Health Network (IHHN) in Pakistan through distance simulation activities.
Methods
This mixed-methods analysis of an educational intervention was conducted at Yale University in collaboration with IHHN. We approached seven U.S. PEM fellows and 22 Pakistani EM residents. We performed a baseline CS assessment using the Clinical Cultural Competency Questionnaire (CCCQ). Afterward, the U.S. PEM fellows facilitated the Pakistani EM residents through six distance simulation sessions. Qualitative data were collected through online focus groups. The CCCQ was analyzed using descriptive statistics, and content analysis was used to analyze the data from the focus groups.
Results
Seven U.S. PEM fellows and 18 of 22 Pakistani EM residents responded to the CCCQ at the beginning of the module. The mean (±SD) CCCQ domain scores for the U.S. PEM fellows versus the Pakistani EM residents were 2.56 (±0.37) versus 2.87 (±0.72) for knowledge, 3.02 (±0.41) versus 3.33 (±0.71) for skill, 2.86 (±0.32) versus 3.17 (±0.73) for encounter/situation, and 3.80 (±0.30) versus 3.47 (±0.47) for attitude (each out of 5 points). Our qualitative data analysis showed that intercultural interactions were valuable. There is a common language of medicine among the U.S. PEM fellows and Pakistani EM residents. The data also highlighted a power distance between the facilitators and learners, as the United States was seen as the standard of “how to practice PEM.” The challenges identified were time differences, cultural practices such as prayer times, the internet, and technology. The use of local language during debriefing was perceived to enhance engagement.
Conclusion
The distance simulation involving U.S. PEM fellows and Pakistani EM residents was an effective approach in assessing various aspects of intercultural education, such as language barriers, technical challenges, and religious considerations.
{"title":"Exploring cultural sensitivity during distance simulations in pediatric emergency medicine","authors":"Jabeen Fayyaz MBBS, MHPE, PhD, Margret Jaeger MPhil, Prisca Takundwa MD, Ammarah U. Iqbal MD, Adeel Khatri MBBS, Saima Ali MBBS, MHPE, Sama Mukhtar MBBS, Syed Ghazanfar Saleem MBBS, Travis Whitfill MPH, MACE, MPhil, Inayat Ali MSc, MPhil, PhD, Jonathan P. Duff MD, MEd, Suzan (Suzie) Kardong-Edgren PhD, Isabel Theresia Gross MD, PhD, MPH","doi":"10.1002/aet2.10908","DOIUrl":"10.1002/aet2.10908","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Cultural sensitivity (CS) training is vital to pediatric emergency medicine (PEM) curricula. This study aimed to explore CS in Yale PEM fellows and emergency medicine (EM) residents at Indus Hospital and Health Network (IHHN) in Pakistan through distance simulation activities.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This mixed-methods analysis of an educational intervention was conducted at Yale University in collaboration with IHHN. We approached seven U.S. PEM fellows and 22 Pakistani EM residents. We performed a baseline CS assessment using the Clinical Cultural Competency Questionnaire (CCCQ). Afterward, the U.S. PEM fellows facilitated the Pakistani EM residents through six distance simulation sessions. Qualitative data were collected through online focus groups. The CCCQ was analyzed using descriptive statistics, and content analysis was used to analyze the data from the focus groups.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Seven U.S. PEM fellows and 18 of 22 Pakistani EM residents responded to the CCCQ at the beginning of the module. The mean (±SD) CCCQ domain scores for the U.S. PEM fellows versus the Pakistani EM residents were 2.56 (±0.37) versus 2.87 (±0.72) for knowledge, 3.02 (±0.41) versus 3.33 (±0.71) for skill, 2.86 (±0.32) versus 3.17 (±0.73) for encounter/situation, and 3.80 (±0.30) versus 3.47 (±0.47) for attitude (each out of 5 points). Our qualitative data analysis showed that intercultural interactions were valuable. There is a common language of medicine among the U.S. PEM fellows and Pakistani EM residents. The data also highlighted a power distance between the facilitators and learners, as the United States was seen as the standard of “how to practice PEM.” The challenges identified were time differences, cultural practices such as prayer times, the internet, and technology. The use of local language during debriefing was perceived to enhance engagement.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>The distance simulation involving U.S. PEM fellows and Pakistani EM residents was an effective approach in assessing various aspects of intercultural education, such as language barriers, technical challenges, and religious considerations.</p>\u0000 </section>\u0000 </div>","PeriodicalId":37032,"journal":{"name":"AEM Education and Training","volume":null,"pages":null},"PeriodicalIF":1.8,"publicationDate":"2023-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138300286","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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