Civility in Health Care: A Moral Imperative

Civility is an essential feature of health care, as it is in so many other areas of human interaction. The article examines the meaning of civility, reviews its origins, and provides reasons for its moral significance in health care. It describes common types of uncivil behavior by health care professionals, patients, and visitors in hospitals and other health care settings, and it suggests strategies to prevent and respond to uncivil behavior, including institutional codes of conduct and disciplinary procedures. The article concludes that uncivil behavior toward health care professionals, patients, and others subverts the moral goals of health care and is therefore unacceptable. Civility is a basic professional duty that health care professionals should embrace, model, and teach.

Intoxication and Glasgow coma scale scores in patients with head trauma

INTRODUCTION

The Glasgow Coma Scale (GCS) is an assessment tool commonly used by emergency department (ED) clinicians to objectively describe level of consciousness, especially in trauma patients. This study aims to assess the effect of drug and alcohol intoxication on GCS scores in cases of traumatic head injury.

METHODS

In this retrospective chart review study, data were extracted from The Pennsylvania Trauma Systems Foundation Data Base Collection System. Eligible subjects included trauma patients aged 18 years and older, with head trauma, who presented between January 2019 and August 2023. Subjects were matched to controls who did not test positive for drugs or alcohol, matched by Injury Severity Score (ISS) category.

RESULTS

Among 1088 subjects, the mean age was 63 (95% CI 62-64). The mean Injury Severity Score was 21 (95% CI 21-22). The median GCS among all subjects was 14 (IQR 6-15). Cases with alcohol or drug use were matched to controls without alcohol or drug use, and were matched by categories of Injury Severity Score. Cases with alcohol or drug use had lower GCS (median 13; IQR 3-15), compared to cases without alcohol or drug use (median 15; IQR 13-15) (p < 0.0001, Wilcoxon Rank Sum Test).

CONCLUSIONS

Among patients with head trauma, intoxicated patients had statistically significant lower GCS scores as compared to matched patients with similar Injury Severity Scores.

Vital signs among emergency department trauma patients in the setting of alcohol or drug use

INTRODUCTION

The incidence of alcohol use among trauma patients has been estimated at 19-55%. This study was undertaken to identify any relationship between vital signs and alcohol and drug use among Emergency Department (ED) patients with trauma.

METHODS

In this retrospective case control study, eligible subjects included trauma patients ages 18 and over, with trauma and drug or alcohol use, between 2018 and 2022. The control group was comprised of trauma patients ages 18 and over, with trauma and no drug or alcohol use, who were matched by Injury Severity Score (ISS). Vital signs on ED arrival were compared among patients with and without alcohol use, and with and without recreational drug use.

RESULTS

Among 16,159 eligible trauma subjects, 5,323 had tests available for drugs and alcohol of whom 2,750 had complete ISS and vital signs data. 684 subjects were identified with alcohol intoxication, 707 subjects were identified with recreational drug use. Patients with alcohol use had lower mean systolic blood pressure (Mean=133, SD=26.7), compared to patients without alcohol use (Mean=143, SD=29.4) (p < 0.001). Patients with alcohol use had higher mean heart rate (Mean=93, SD=19.9) compared to patients without alcohol use (Mean=91, SD=19.7) (p = 0.01). Patients with recreational drug use had lower mean systolic blood pressure (Mean=137, SD=28.5) compared to patients without drug use (Mean=143, SD=29.6) (p < 0.001). Patients with drug use had higher mean heart rate (Mean=94, SD=22.8), compared to patients without drug use (Mean=91, SD=20.0) (p = 0.002). Cannabinoids were associated with lower SBP (Case Mean=136 (25.4) vs. Control Mean=141 (31.0), p = 0.009). Opioids were associated with lower SBP (Case Mean=138 (28.0) vs. Control Mean=145 (29.4), p = 0.01). Benzodiazepines were associated with increased HR and decreased SBP and RR.

CONCLUSIONS

There appear to be no clinically relevant differences in vital signs among trauma patients with drug use and/or alcohol use, compared to patients without drug or alcohol use. Abnormal vital signs should not be prematurely attributed solely to acute substance intoxication before fully evaluating for associated traumatic injuries.

Delayed Diagnosis of Intracranial Trauma

Introduction Trauma is one of the leading causes of death and hospitalization in the United States. Head trauma often results in significant morbidity and mortality. This study was undertaken to identify reasons for delay in diagnosis of intracranial trauma. Methods This retrospective study analyzed patients with intracranial trauma between 2016 and 2022, in which there was a delay of two days or more from the date of injury to the date of diagnosis. Results Among 809 patients with head trauma, 140 subjects were identified with delayed diagnosis of intracranial trauma (17.3%). The most common diagnoses were subdural hemorrhage (N = 82; 56%) and intraparenchymal hemorrhage (N = 33; 24%). The most common reasons for delay in diagnosis included patient delay in seeking care (N = 111; 79%), and delayed diagnosis during inpatient hospitalization (N = 16; 11%) (Chi-Square <0.0001) (Table 2). Among inpatients with delayed diagnosis, confounding issues included alcohol intoxication (N = 4; 3%), other injuries (N = 9; 6%), and mental health issues (N = 2; 1%). Conclusions Among patients with delayed diagnosis of intracranial trauma, the majority of delays in diagnosis were due to patient delay in seeking care. Future directions may include improved public education regarding trauma and the importance of seeking timely medical care.

Factors associated with emergency physician income

Objective

Income fairness is important, but there are limited data that describe income equity among emergency physicians. Understanding the magnitude of and factors associated with income differences may be helpful in eliminating disparities. This study analyzed the associations of demographic factors, training, practice setting, and board certification with emergency physician income.

Methods

We distributed a survey to professional members of the American College of Emergency Physicians. The survey included questions on annual income, educational background, practice characteristics, gender, age, race, ethnicity, international medical graduate status, type of medical degree (MD vs DO), completion of a subspecialty fellowship, job characteristics, and board certification. Respondents also reported annual income. We used linear regression to determine the respondent characteristics associated with reported annual income.

Results

From 45,961 members we received 3407 responses (7.4%); 2350 contained complete data for regression analysis. The mean reported annual income was $315,306 (95% confidence interval [CI], $310,649 to $319,964). The mean age of the respondents was 47.4 years, 37.4% were women, 3.2% were races underrepresented in medicine (Black, American Indian, or Alaskan Native), and 4.8% were Hispanic or Latino. On linear regression, female gender was associated with lower reported annual income; difference -$43,565, 95% CI, -$52,217 to -$34,913. Physician age, degree (MD vs DO), underrepresented racial minority status, and underrepresented ethnic minority status were not associated with annual income. Fellowship training was associated with lower income; Accreditation Council for Graduate Medical Education (ACGME) program difference -$30,048; 95% CI, -$48,183 to -$11,912, non-ACGME-program difference -$27,640, 95% CI, -$40,970 to -$14,257. Working at a for-profit institution was associated with higher income; difference $12,290, 95% CI, $3693 to $20,888. Board certification was associated with higher income; difference, $43,267, 95% CI, $30,767 to $55,767.

Conclusions

This study identified income disparities associated with gender, practice setting, fellowship completion, and American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine certification.

Law enforcement information gathering in the emergency department: Legal and ethical background and practical approaches

In the course of legal investigations, law enforcement officers may enlist emergency department (ED) personnel to gather information or forensic evidence, often with the intent of building cases against a patient. These situations create ethical conflicts between the emergency physician's obligations to the patient and society. This paper provides an overview of the ethical and legal considerations in ED forensic evidence collection and the general principles that emergency physicians should apply in these situations.

Penetrating trauma: Relationships to recreational drug and alcohol use

INTRODUCTION

The incidence of alcohol and recreational drug use is increasing. The impact on penetrating trauma is unknown. This study was undertaken to identify the incidence of alcohol and recreational drug use prior to penetrating trauma, and to identify ISS and outcomes among patients with penetrating trauma.

METHODS

In this retrospective study, eligible subjects included trauma patients age 18 and older, with major trauma (admitted or evaluated by the Trauma Team) from 2017 to 2021. A chart review was conducted to identify data including mechanism of injury, ISS, alcohol level, toxicologic testing, length of stay, and final disposition.

RESULTS

Among 1270 adult subjects with penetrating trauma during 2017 through 2020, the majority were male (N = 1071; 84%), and African American (N = 679; 54.3%) or White (N = 537; 42.9%). Mechanisms of injury included gunshot wound (GSW) (N = 973; 76.6%) or stab wound (N = 297; 23.4%). Injury severity score (ISS) ranged from 1 to 75. Among 426 subjects (33.5%) tested for recreational drugs, 395 (93%) were positive for at least one substance. The most common recreational drugs identified included marijuana (N = 280; 65.7%), benzodiazepine ((N = 131;30.8%), alcohol ((N = 248; 25.3%), opiate ((N = 116; 27.2%), cocaine (N = 87; 20.4%), and amphetamine ((N = 84; 19.7%). Subjects with an ISS of 9 to 15 had higher odds of testing positive for opiates compared to subjects with an ISS of 1 to 3 (OR 2.3). Most patients were ultimately discharged home ((N = 912;71.8%) and a minority expired (N = 142; 11.2%).

CONCLUSIONS

Positive screens for alcohol and recreational drugs were common among penetrating trauma patients in this setting. The most common identified recreational drugs included marijuana, benzodiazepine, opiates, alcohol, cocaine, and amphetamine.

The Emergency Medicine Physician Workforce: Projections for 2030

STUDY OBJECTIVE

The goals of this study were to determine the current and projected supply in 2030 of contributors to emergency care, including emergency residency-trained and board-certified physicians, other physicians, nurse practitioners, and physician assistants. In addition, this study was designed to determine the current and projected demand for residency-trained, board-certified emergency physicians.

METHODS

To forecast future workforce supply and demand, sources of existing data were used, assumptions based on past and potential future trends were determined, and a sensitivity analysis was conducted to determine how the final forecast would be subject to variance in the baseline inputs and assumptions. Methods included: (1) estimates of the baseline workforce supply of physicians, nurse practitioners, and physician assistants; (2) estimates of future changes in the raw numbers of persons entering and leaving that workforce; (3) estimates of the productivity of the workforce; and (4) estimates of the demand for emergency care services. The methodology assumes supply equals demand in the base year and estimates the change between the base year and 2030; it then compares supply and demand in 2030 under different scenarios.

RESULTS

The task force consensus was that the most likely future scenario is described by: 2% annual graduate medical education growth, 3% annual emergency physician attrition, 20% encounters seen by a nurse practitioner or physician assistant, and 11% increase in emergency department visits relative to 2018. This scenario would result in a surplus of 7,845 emergency physicians in 2030.

CONCLUSION

The specialty of emergency medicine is facing the likely oversupply of emergency physicians in 2030. The factors leading to this include the increasing supply of and changing demand for emergency physicians. An organized, collective approach to a balanced workforce by the specialty of emergency medicine is imperative.

Radiographic findings of SARS-CoV-2 infection

STUDY OBJECTIVE

The 2019-20 coronavirus pandemic is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19). This study was undertaken to identify and compare findings of chest radiography and computed tomography among patients with SARS-CoV-2 infection.

METHODS

This retrospective study was undertaken at a tertiary care center. Eligible subjects included consecutive patients age 18 and over with documented SARS-CoV-2 infection between March and July 2020. The primary outcome measures were results of chest radiography and computed tomography among patients with documented SARS-CoV-2 infection.

RESULTS

Among 724 subjects, most were admitted to a medical floor (46.4%; N = 324) or admitted to an ICU (10.9%; N = 76). A substantial number of subjects were intubated during the emergency department visit or inpatient hospitalization (15.3%; N = 109). The majority of patients received a chest radiograph (80%; N = 579). The most common findings were normal, bilateral infiltrates, ground-glass opacities, or unilateral infiltrate. Among 128 patients who had both chest radiography and computed tomography, there was considerable disagreement between the 2 studies (52.3%; N = 67; 95% confidence interval: 43.7% to 61.0%).). The presence of bilateral infiltrates (infiltrates or ground-glass opacities) was associated with clinical factors including older age, ambulance arrivals, more urgent triage levels, higher heart rate, and lower oxygen saturation. Bilateral infiltrates were associated with poorer outcomes, including higher rate of intubation, greater number of inpatient days, and higher rate of death.

CONCLUSIONS

Common radiographic findings of SARS-CoV-2 infection include infiltrates or ground-glass opacities. There was considerable disagreement between chest radiography and computed tomography. Computed tomography was more accurate in defining the extent of involved lung parenchyma. The presence of bilateral infiltrates was associated with morbidity and mortality.

Post-traumatic stress and stress disorders during the COVID-19 pandemic: Survey of emergency physicians

OBJECTIVE

Emergency physicians routinely encounter stressful clinical situations, including treating victims of crime, violence, and trauma; facing the deaths of patients; and delivering bad news. During a pandemic, stress may be increased for healthcare workers. This study was undertaken to identify symptoms of post-traumatic stress disorder (PTSD) among emergency physicians during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This cross-sectional survey was developed using the Life Events Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (DSM-5) and the PTSD Checklist for DSM-5 (PCL-5). The survey was distributed to members of the American College of Emergency Physicians from May 21, 2020, through June 22, 2020.

RESULTS

Among 1300 emergency physicians, a significant number of participants (22.3%; 95% confidence interval, 20.3-24.3%) reported symptoms of stress consistent with PTSD (PCL score ≥ 33). Higher PCL-5 scores were associated with age younger than 50 years (P < 0.05) and <10 years in practice (P < 0.05). The major sources of stress identified by participants included disinformation about COVID-19, computer work/electronic medical record, personal protective equipment concerns, and workload. The most common consequences of workplace stress were feeling distant or cut off from other people and sleep disturbance, such as trouble falling or staying asleep.

CONCLUSIONS

A significant number of emergency physicians reported symptoms of stress consistent with PTSD. Higher PCL-5 scores were associated with age younger than 50 years and <10 years in practice.

Advance directives in the emergency department

Advance directives are documents to convey patients' preferences in the event they are unable to communicate them. Patients commonly present to the emergency department near the end of life. Advance directives are an important component of patient-centered care and allow the health care team to treat patients in accordance with their wishes. Common types of advance directives include living wills, health care power of attorney, Do Not Resuscitate orders, and Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST). Pitfalls to use of advance directives include confusion regarding the documents themselves, their availability, their accuracy, and agreement between documentation and stated bedside wishes on the part of the patient and family members. Limitations of the documents, as well as approaches to addressing discrepant goals of care, are discussed.

The perils of recreational marijuana use: relationships with mental health among emergency department patients

INTRODUCTION

Marijuana is a commonly used drug in the United States. Many states have legalized the recreational use of marijuana. The effects of marijuana on mental health are unknown.

METHODS

In this prospective survey study, eligible participants included ED patients age 18 and older, who had ever used recreational marijuana. A survey instrument was developed, piloted, and revised. Data collected included reasons for marijuana use, marijuana's perceived effectiveness, and history of mental health conditions, including depression, anxiety, and suicidal thoughts.

RESULTS

Among 303 participants (86% response rate), the median age of first marijuana use was 16 ([IQR 14, 19], range 6-65). The most commonly cited reasons for marijuana use included recreational use (70%; n = 211), to treat anxiety (30%; n = 89), to treat pain (25%; n = 74), and to treat depression (17%; n = 51). Mental health issues were common in the study population. A majority of patients reported anxiety in the last 30 days (59%; n = 176), and a significant minority of patients reported serious depression in the last 30 days (46%; n = 137). Some patients reported suicidal thoughts in the last 30 days (9%; n = 29). Participants who used marijuana more frequently reported more days of anxiety (median 15.5, compared to 1; P = 0.001). Among participants with mental health conditions, most began using marijuana before the onset of the mental health conditions (77%, n = 167). Earlier age of starting to use marijuana was correlated with higher number of years of anxiety or tension in lifetime (r = -0.11, P = 0.05, n = 301). Perceived effects of marijuana use on mental health were variable. Most participants stated that marijuana improved their mental health (62%; n = 163), and some reported that marijuana did not improve their mental health (37%; n = 98).

CONCLUSIONS

Many ED patients have used marijuana, either currently or in the past. Mental health conditions are also common, including anxiety, depression, and suicidal thoughts. Most participants reported marijuana use starting at an age under 18. Marijuana use preceded the onset of mental health conditions in the majority of participants.

Predictors of new-onset atrial fibrillation in geriatric trauma patients

INTRODUCTION

Geriatric patients (age >65) comprise a growing segment of the trauma population. New-onset atrial fibrillation may occur after injury, complicating clinical management and resulting in significant morbidity and mortality. This study was undertaken to identify clinical and demographic factors associated with new-onset atrial fibrillation among geriatric trauma patients.

METHODS

In this case control study, eligible participants included admitted trauma patients age 65 and older who developed new-onset atrial fibrillation during the hospitalization. Controls were admitted trauma patients who were matched for age and injury severity score, who did not develop atrial fibrillation. We evaluated the associations between new-onset atrial fibrillation and clinical characteristics, including patient demographics, health behaviors, chronic medical conditions, and course of care.

RESULTS

Data were available for 63 cases and 25 controls. Patients who developed atrial fibrillation were more likely to be male, compared to controls (49% versus 24%; odds ratio 3.0[1.0, 8.9]). Other demographic and clinical factors were not associated with new-onset atrial fibrillation, including mechanism of injury, co-morbid medical conditions, drug or alcohol use, surgical procedures, and intravenous fluid administration.

CONCLUSIONS

Male geriatric trauma patients were at higher risk for developing new-onset atrial fibrillation. Other demographic and clinical factors were not associated with new-onset atrial fibrillation.

Mandatory and permissive reporting laws: obligations, challenges, moral dilemmas, and opportunities

The duty to report certain conditions to public health or law enforcement authorities is one that falls on all physicians and other health care workers as part of their duty to protect the public from harm. In an open society, others, such as teachers, clergy, police officers, or simply neighbors, share the responsibility of protecting individuals at risk, often by reporting them to authorities. The emergency physician and others in the emergency department are uniquely positioned to identify people at risk or who pose a risk, and to report them as required or allowed under the law. In some circumstances, these duties may conflict with ethical duties such as respect for patient autonomy or to protect confidentiality. This article will examine mandatory and permissive reporting laws in various states from an ethical perspective. It will also explore emerging issues such as the reporting of suspected human trafficking.

Assessing psychiatric safety in suicidal emergency department patients

We provide a review of the assessment of suicidal emergency department patients and includes a legal and ethical perspective. Screening tools and psychiatric consultation are important adjuncts to the ED evaluation of potentially suicidal patients. Suicide risk should be assessed, and if positive, an appropriate and safe disposition should be arranged. The aim of this article is to review these assessment tools and consider ethical issues, such as patient autonomy, accountability of the emergency physician, and consultant to Emergency Medical Treatment and Labor Act (EMTALA) as well as confidentiality, privacy, and social issues.

Refusal of emergency medical care: An analysis of patients who left without being seen, eloped, and left against medical advice

OBJECTIVE

Emergency department (ED) patients may elect to refuse any aspect of medical care. They may leave prior to physician evaluation, elope during treatment, or leave against medical advice during treatment. This study was undertaken to identify patient perspectives and reasons for refusal of care.

METHODS

This prospective study was conducted at an urban Level 1 Trauma Center. This study examined ED patients who left without being seen (LWBS), eloped during treatment, or left against medical advice during September to December 2018. This project included both chart review and a prospective patient survey.

RESULTS

Among 298 participants, the majority were female (54%). Most participants were White (61%) or African American (36%). Thirty-eight percent of participants left against medical advice, 23% eloped, and 39% left without being seen by a provider. When compared to the general ED population, patients who refused care were significantly younger (p < 0.001). When comparing by groups, patients who left AMA were significantly older than those who eloped or left without being seen (p < 0.001). Among 68 patients interviewed by telephone, the most common stated reasons for refusal of care included wait time (23%), unmet expectations (23%), and negative interactions with ED staff (15%).

CONCLUSION

ED patients who refused care were significantly younger than the general ED population. Common reasons cited by patients for refusal of care included wait time, unmet expectations, and negative interactions with ED staff.

Emergency Medicine in the #MeToo Era

Sexual harassment is a serious threat to a safe and productive workplace. The emergency department (ED) environment poses unique threats, including stress, time constraints, working in close physical proximity, and frequent personal contacts with staff, colleagues, consultants, and difficult patients. Sexual harassment must be recognized and addressed in individual cases, in policy and in law, to protect staff members and patients. This article addresses the scope of the problem of sexual harassment known to date. It describes the ED environment and culture and why they may be conducive to harassment or abusive behavior. The authors examine relationships among staff, legal and regulatory issues, and strategies for prevention and remediation of inappropriate behavior. The article ends with a call for future research.

Seat belt use among patients in motor vehicle collisions: Clinical and demographic factors

OBJECTIVE

Proper use of automobile seat belt in a motor vehicle crash is associated with reduced morbidity and mortality, shorter hospital stays, reduced resource utilization, and fewer missed work days. Seatbelt compliance nationwide is 86%. This study was undertaken to identify factors associated with noncompliance with seatbelt use among admitted patients following a motor vehicle crash.

METHODS

This study was a retrospective analysis of motor vehicle crashes at an Urban Level 1 Trauma Center. Eligible subjects included patients age 18 and over, who were admitted by the Trauma Service following a motor vehicle crash from January to December 2017.

RESULTS

Among 766 participants, the overall rate of seatbelt noncompliance was 32% (N = 245). Some participants met the legal limit of intoxication (80 mg/dl) (N = 119 patients; 22%). Drug use was high among this population, including THC (30%), opiates (29%), benzodiazepines (24%), cocaine (10%), and methamphetamine (10%). Patients who did not wear seat belts were more likely to be male (62.4% no seat belt vs. 51.8% seat belt), intoxicated (30.5% vs. 17.0%), screen positive for cocaine (18.2% vs. 4.7%), THC (37.7% vs. 24.2%), and methamphetamine (15.6% vs. 5.9%). We did not detect significant differences by seat belt use with respect to ethnicity, mode of arrival, day of week, opiate use, or benzodiazepine use.

CONCLUSIONS

In this study, 32% of patients in motor vehicle crashes were not compliant with seat belt use. Noncompliance with seat belt use was higher among patients who were male, younger age, intoxicated, or who had positive screens for cocaine, THC, or methamphetamine.

Emergency physician care of family members, friends, colleagues and self

Emergency Physicians are frequently called upon to treat family members, friends, colleagues, subordinates or others with whom they have a personal relationship; or they may elect to treat themselves. This may occur in the Emergency Department (ED), outside of the ED, as an informal, or "curbside" consultation, long distance by telecommunication or even at home at any hour. In surveys, the vast majority of physicians report that they have provided some level of care to family members, friends, colleagues or themselves, sometime during their professional career. Despite being common, this practice raises ethical concerns and concern for the welfare of both the patient and the physician. This article suggests ethical and practical guidance for the emergency physician as to how to approach these situations.

Naloxone Use Among Emergency Department Patients with Opioid Overdose

BACKGROUND

Emergency department (ED) visits for unintentional opioid overdoses have increased dramatically. Naloxone hydrochloride (Narcan®) is an opioid antagonist commonly used to treat these overdoses.

OBJECTIVE

This study was undertaken to identify experiences regarding naloxone use among ED patients with opioid overdose.

METHODS

This prospective survey study was conducted at an urban level I trauma center. A survey was administered to eligible ED patients after unintentional opioid overdose. This study identified current and previous use of naloxone among ED patients with opioid overdose.

RESULTS

Eight-nine ED patients with accidental overdose of opioids participated (90% participation rate). Most participants reported a history of opioid overdose (n = 62 [70%]). A significant minority stated they have had access to a naloxone kit (n = 28 [31%]). Most participants with a naloxone kit stated that their frequency and dosage of opiate use did not change after access to naloxone (n = 17 [63%]), and a few used opiates more often (n = 1 [4%]) or less often (n = 9 [33%]). There was a significant negative correlation between total dose and age (Spearman ρ -0.27; p = 0.01). There was no association between dose and sex.

CONCLUSIONS

Many patients presenting with opioid overdose have had a history of opioid overdose. Patients with opioid overdose required a highly variable dose of naloxone. Higher doses of naloxone were associated with lower age. Despite widespread availability of naloxone to consumers, a minority of patients in this study reported access to naloxone. Participants who had access to a naloxone kit stated that their frequency and dosage of opioid use did not change.

American Board of Emergency Medicine Report on Residency and Fellowship Training Information (2017-2018)

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine-sponsored residency and fellowship programs, as well as the residents and fellows training in those programs. We present the 2018 annual report on the status of US emergency medicine training programs.

Emergency medicine practice environment and impact on concert examination performance

OBJECTIVE

The ABEM ConCert Examination is a summative examination that ABEM-certified physicians are required to pass once in every 10-year cycle to maintain certification. This study was undertaken to identify practice settings of emergency physicians, and to determine if there was a difference in performance on the 2017 ConCert between physicians of differing practice types and settings.

METHODS

This was a mixed methods cross sectional-study, using a post-examination survey and test performance data. All physicians taking the 2017 ConCert Examination who completed three survey questions pertaining to practice type, practice locations, and teaching were included. These three questions address different aspects of academia: self-identification, an academic setting, and whether the physician teaches.

RESULTS

Among 2796 test administrations of the 2017 ConCert Examination, 2693 (96.3%) completed the three survey questions about practice environment. The majority (N = 2054; 76.3%) self-identified as primarily being a community physician, 528 (19.6%) as academic, and 111 (4.1%) as other. The average ConCert Examination score for community physicians was 83.5 (95% CI, 83.3-83.8); the academic group was 84.8 (95% CI, 84.3-85.3); and the other group was 82.3 (95% CI, 81.1-83.6). After controlling for initial ability as measured by the Qualifying Examination score, there was no significant difference in performance between academic and community physicians (p = .10).

CONCLUSIONS

Academic emergency physicians and community emergency physicians scored similarly on the ConCert. Working at a community teaching hospital was associated with higher examination performance. Teaching medical learners, especially non-emergency medicine residents, was also associated with better examination performance.

Physician Age and Performance on the American Board of Emergency Medicine ConCert Examination

OBJECTIVE

This study was undertaken to expand on results from a 2014 study on the association between physician age and performance on the American Board of Emergency Medicine (ABEM) ConCert examination.

METHODS

This was a retrospective, longitudinal growth study comparing performance on the ConCert examination and physicians' ages at the time of examination. All examination attempts from 1990 to 2016 made by residency-trained physicians were eligible for inclusion. Multilevel growth models were constructed to examine the relationship between age at time of examination and performance, controlling for physician characteristics.

RESULTS

The study group included 15,533 examination attempts by 12,786 physicians. The mean (±SD) age of the physicians across all examination administrations was 45.02 (±5.18) years (range = 35 to 72 years). The mean (±SD) ConCert examination score across all administrations was 85.39 (±5.71; range = 51 to 100). Among first-time ConCert examination takers, older age was associated with lower examination scores (r = -0.25, p < 0.0001). Across all examination attempts, age was negatively correlated to examination scores (r = -0.24; p < 0.0001).

CONCLUSIONS

After physician characteristics were controlled for, there was an association between advancing age and declining performance on the ABEM ConCert examination. This information may be important to the individual physician to develop targeted competency assessment and professional development.

Conflicts of Interest in Emergency Medicine

Conflicts of interest (COIs) are common in the practice of emergency medicine and may be present in the areas of clinical practice, relations with industry, expert witness testimony, medical education, research, and organizations. A COI occurs when there is dissonance between a primary interest and another interest. The concept of professionalism in medicine places the patient as the primary interest in any interaction with a physician. We contend that patient welfare is the ultimate interest in the entire enterprise of medicine. Recognition and management of potential, real, and perceived COIs is essential to the ethical practice of emergency medicine. This paper discusses how to recognize, address, and manage them.

American Board of Emergency Medicine Report on Residency and Fellowship Training Information (2016-2017)

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency programs and the residents training in those programs. We present the 2017 annual report on the status of US emergency medicine training programs.

Evolution of the Model of the Clinical Practice of Emergency Medicine: 1979 to Present

The Model of the Clinical Practice of Emergency Medicine (the EM Model) is a three-dimensional representation of the clinical practice of emergency medicine. It is a product of successful collaboration involving the American Board of Emergency Medicine (ABEM), the American College of Emergency Physicians (ACEP), the Society for Academic Emergency Medicine (SAEM), the Emergency Medicine Residents' Association (EMRA), the Council of Emergency Medicine Residency Directors (CORD), the Residency Review Committee for Emergency Medicine (RRC-EM), and the American Academy of Emergency Medicine (AAEM). In 2017, the most recent update and revision of the EM Model will be published. This document will represent the culmination of nearly 40 years of evolution, from a simple listing of presenting patient complaints, clinical symptoms, and disease states into a three-dimensional representation of the clinical practice of emergency medicine. These dimensions include conditions and components, physician tasks, and patient acuity. In addition, over the years, two other documents have been developed, the Knowledge, Skills, and Abilities (KSAs) and the Emergency Medicine Milestones. Both serve as related and complementary educational and assessment tools. This article will review the development of the EM Model from its inception in 1979 to today.

The Relationship Between ACGME Duty Hour Requirements and Performance on the American Board of Emergency Medicine Qualifying Examination

BACKGROUND

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) instituted requirements that limited the number of hours residents could spend on duty, and in 2011, it revised these requirements.

OBJECTIVE

This study explored whether the implementation of the 2003 and 2011 duty hour limits was associated with a change in emergency medicine residents' performance on the American Board of Emergency Medicine (ABEM) Qualifying Examination (QE).

METHODS

Beginning with the 1999 QE and ending with the 2014 QE, candidates for whom all training occurred without duty hour requirements (Group A), candidates under the first set of duty hour requirements (Group C), and candidates under the second set of duty hour requirements (Group E) were compared. Comparisons included mean scores and pass rates.

RESULTS

In Group A, 5690 candidates completed the examination, with a mean score of 82.8 and a 90.2% pass rate. In Group C, 8333 candidates had a mean score of 82.4 and a 90.5% pass rate. In Group E, there were 1269 candidates, with a mean score of 82.5 and an 89.4% pass rate. There was a small but statistically significant decrease in the mean scores (0.04, P < .001) after implementation of the first duty hour requirements, but this difference did not occur after implementation of the 2011 standards. There was no difference among pass rates for any of the study groups (χ² = 1.68, P = .43).

CONCLUSIONS

We did not identify an association between the 2003 and 2011 ACGME duty hour requirements and performance of test takers on the ABEM QE.

The American Board of Emergency Medicine ConCert Examination: Emergency Physicians' Perceptions of Learning and Career Benefits

OBJECTIVE

As part of the American Board of Emergency Medicine (ABEM) Maintenance of Certification (MOC) program, ABEM-certified physicians are required to pass the Continuous Certification (ConCert) examination at least every 10 years. With the 2015 ConCert examination, ABEM sought to better understand emergency physicians' perceptions of the benefits of preparing for and taking the examination and the career benefits of staying ABEM-certified.

METHODS

This was a prospective survey study. A voluntary postexamination survey was administered at the end of the 2015 ABEM ConCert examination (September 21-26, 2015). Physicians were asked about the benefits of preparing for the examination and maintaining ABEM certification. Examination performance was compared to perceptions of learning and career benefits.

RESULTS

Of the 2,601 on-time test takers, 2,511 respondents participated (96.5% participation rate). The majority of participants (92.0%) identified a benefit to preparing for the ConCert examination, which included reinforced medical knowledge (73.9%), increased knowledge (66.8%), and making them a better clinician (39.4%). The majority of respondents (90.8%) identified a career benefit of maintaining ABEM certification, which included more employment options (73.8%), more positively viewed by other physicians (56.8%), and better financial outcomes (29.8%). There was a statistically significant association between the perception of knowledge reinforcement and examination performance (p < 0.001). There was also a statistically significant association between the perception that staying certified created more career opportunities and examination performance (p < 0.001).

CONCLUSIONS

Most emergency physicians identified benefits of preparing for and taking the ABEM ConCert examination, which included reinforcing or adding medical knowledge and making them better clinicians. Most physicians also found career benefits to remaining ABEM-certified, which included greater employment choices, higher financial compensation, and higher esteem from other physicians. The belief that preparing for and taking the examination reinforced medical knowledge was associated with better examination performance.