Authors' Response to the Validity of Cortisol and Galvanic Skin Responses for Measuring Student Stress During Training

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Gender Evaluation and Numeric Distribution in Emergency Medicine Residencies (GENDER): A Retrospective Analysis of Gender Ratios Among Residents and Residency Directors from 2014-2017

Introduction: While females make up more than half of medical school matriculants, they only comprise about one third of emergency medicine (EM) residents. We examined EM residency cohorts with entering years of 2014–2017 to estimate the ratio of males to females among residents and program leadership to determine what correlation existed, if any, between program leadership and residency gender distributions. Methods: We identified 171 accredited EM residency programs in the United States with resident cohorts entering between 2014-2017 with publicly available data that were included in the study. The number of male and female residents and program directors were counted. We then confirmed the counts by contacting the programs directly to confirm accuracy of the data collected from program websites. Results: Within the included 171 programs, the overall male to female EM resident ratio was 1.78:1. Individual program ratios ranged from 0.85-8.0. Only eight programs (5.6%) had a female-predominant ratio. Among program directors, the overall male to female ratio was 2.17:1. TThe gender of the program director did not have a statistically significant correlation with the male to female ratio among its residents (P = .93). Conclusion: Within 171 residency programs across the US with entering cohorts between 2014-2017, the average male to female ratio among residents is nearly 2:1. No significant correlation exists between the gender distribution among a program’s leadership and its residents.

Comparing the Psychological Effects of Manikin-Based and Augmented Reality-Based Simulation Training: Within-Subjects Crossover Study

BACKGROUND

Patient simulators are an increasingly important part of medical training. They have been shown to be effective in teaching procedural skills, medical knowledge, and clinical decision-making. Recently, virtual and augmented reality simulators are being produced, but there is no research on whether these more realistic experiences cause problematic and greater stress responses as compared to standard manikin simulators.

OBJECTIVE

The purpose of this research is to examine the psychological and physiological effects of augmented reality (AR) in medical simulation training as compared to traditional manikin simulations.

METHODS

A within-subjects experimental design was used to assess the responses of medical students (N=89) as they completed simulated (using either manikin or AR) pediatric resuscitations. Baseline measures of psychological well-being, salivary cortisol, and galvanic skin response (GSR) were taken before the simulations began. Continuous GSR assessments throughout and after the simulations were captured along with follow-up measures of emotion and cortisol. Participants also wrote freely about their experience with each simulation, and narratives were coded for emotional word use.

RESULTS

Of the total 86 medical students who participated, 37 (43%) were male and 49 (57%) were female, with a mean age of 25.2 (SD 2.09, range 22-30) years and 24.7 (SD 2.08, range 23-36) years, respectively. GSR was higher in the manikin group adjusted for day, sex, and medications taken by the participants (AR-manikin: -0.11, 95% CI -0.18 to -0.03; P=.009). The difference in negative affect between simulation types was not statistically significant (AR-manikin: 0.41, 95% CI -0.72 to 1.53; P=.48). There was no statistically significant difference between simulation types in self-reported stress (AR-manikin: 0.53, 95% CI -2.35 to 3.42; P=.71) or simulation stress (AR-manikin: -2.17, 95% CI -6.94 to 2.59; P=.37). The difference in percentage of positive emotion words used to describe the experience was not statistically significant between simulation types, which were adjusted for day of experiment, sex of the participants, and total number of words used (AR-manikin: -4.0, 95% CI -0.91 to 0.10; P=.12). There was no statistically significant difference between simulation types in terms of the percentage of negative emotion words used to describe the experience (AR-manikin: -0.33, 95% CI -1.12 to 0.46; P=.41), simulation sickness (AR-manikin: 0.17, 95% CI -0.29 to 0.62; P=.47), or salivary cortisol (AR-manikin: 0.04, 95% CI -0.05 to 0.13; P=.41). Finally, preexisting levels of posttraumatic stress disorder, perceived stress, and reported depression were not tied to physiological responses to AR.

CONCLUSIONS

AR simulators elicited similar stress responses to currently used manikin-based simulators, and we did not find any evidence of AR simulators causing excessive stress to participants. Therefore, AR simulators are a promising tool to be used in medical training, which can provide more emotionally realistic scenarios without the risk of additional harm.

No difference in factual or conceptual recall comprehension for tablet, laptop, and handwritten note-taking by medical students in the United States: a survey-based observational study

PURPOSE

Technological advances are changing how students approach learning. The traditional note-taking methods of longhand writing have been supplemented and replaced by tablets, smartphones, and laptop note-taking. It has been theorized that writing notes by hand requires more complex cognitive processes and may lead to better retention. However, few studies have investigated the use of tablet-based note-taking, which allows the incorporation of typing, drawing, highlights, and media. We therefore sought to confirm the hypothesis that tablet-based note-taking would lead to equivalent or better recall as compared to written note-taking.

METHODS

We allocated 68 students into longhand, laptop, or tablet note-taking groups, and they watched and took notes on a presentation on which they were assessed for factual and conceptual recall. A second short distractor video was shown, followed by a 30-minute assessment at the University of California, Irvine campus, over a single day period in August 2018. Notes were analyzed for content, supplemental drawings, and other media sources.

RESULTS

No significant difference was found in the factual or conceptual recall scores for tablet, laptop, and handwritten note-taking (P=0.61). The median word count was 131.5 for tablets, 121.0 for handwriting, and 297.0 for laptops (P=0.01). The tablet group had the highest presence of drawing, highlighting, and other media/tools.

CONCLUSION

In light of conflicting research regarding the best note-taking method, our study showed that longhand note-taking is not superior to tablet or laptop note-taking. This suggests students should be encouraged to pick the note-taking method that appeals most to them. In the future, traditional note-taking may be replaced or supplemented with digital technologies that provide similar efficacy with more convenience.

Influence of Factors Relating to Sex and Gender on Rank List Decisions and Perceptions of Residency Training: Survey Study

BACKGROUND

Females make up more than half of medical school matriculants but only one-third of emergency medicine (EM) residents. Various factors may contribute to why fewer females choose the field of EM, such as the existing presence of females in the specialty.

OBJECTIVE

This study is a follow-up to previous work, and a survey is used to assess current residents' attitudes and perceptions on various factors, including those relating to sex and gender on creating rank lists as medical students and in perceived effects on residency education.

METHODS

A web-based survey consisting of Likert scale questions regarding a variety of factors influencing a student's decision to create a rank list and in perceived effects on residency education was sent to current EM residents in 2020.

RESULTS

Residents from 17 programs participated in the survey with an 18.2% (138/758) response rate. The most important factors in creating a rank list were the personality of residents in the program, location, and facility type. For factors specifically related to gender, respondents who answered affirmatively to whether the gender composition of residents affected the selection of a program in making a rank list were more likely to also answer affirmatively to subsequent questions related to the gender of program leadership (P<.001) and gender composition of attending physicians (P<.001). The personality of residents was also the most important factor perceived to affect residency education. For factors influencing rank list and residency education, female respondents placed higher importance on subcategories related to gender (ie, gender composition of the residents, of the program leadership, and of the attending physicians) to a significant degree compared with their male counterparts.

CONCLUSIONS

Although factors such as location and resident personality show the most importance in influencing residency selection, when stratifying based on respondent sex, females tend to indicate that factors relating to gender have more influence on rank list and residency education compared with males.

The Applied Weighted Slide Metric (AWSM) Tool: Creation of a Standard Slide Design Rubric

INTRODUCTION

Lectures are a standard aspect across all realms of medical education. Previous studies have shown that visual design of presentation slides can affect learner outcomes. The purpose of this study was to develop a slide design rubric grounded in evidence-based, multimedia principles to enable objective evaluation of slide design.

METHOD

Using the principles described in Mayers' Principles of Multimedia Learning and Duarte's Slide:ology, the authors extracted nineteen items important for slide design. We developed an online, rank-item, survey tool to identify the importance of each item among medical educators. Respondents selected which slide design principles they felt were important when attending a lecture/didactic session and ranked their relative importance.

RESULTS

We received 225 responses to the survey. When asked to specifically rank elements from most important to least important, participants gave the most weight to "readability of figures and data" and "[lack of] busy-ness of slide." The lowest ranked elements were "transitions and animations" and "color schemes". Using the results of the survey, including the free response, we developed a rubric with relative weighting that followed our survey data.

CONCLUSION

With this information we have applied values to the various aspects of the rubric for a total score of 100. We hope that this rubric can be used for self-assessment or to evaluate and improve slides for educators. Future research will be focused on implementing and validating the slide design survey and ensuring it is easily usable with a high inter-rater reliability and whether self-assessment with the rubric improves presentation design and education quality.

Implementation of an Electronic Health Record-Based Messaging System in the Emergency Department: Effects on Physician Workflow and Resident Burnout

INTRODUCTION

The traditional methods of communication between nurses and physicians through paging or phone calls have been known to cause patient care interruptions, increase stress and workload, and cause burnout. Our study assessed the impact of using an electronic health record-based messaging system (Epic Secure Chat) for nonemergent communication between nurses and physicians in the emergency department (ED).

METHOD

This study was performed at a large urban academic ED. Surveys were distributed through e-mail using Google forms. Preimplementation and postimplementation surveys were performed from May 2019 (presurvey) to August 2019 (postsurvey).

RESULT

The number of nonurgent phone calls from registered nurse staff decreased after intervention (P < 0.001). The frequency of nonurgent calls disrupting workflow decreased after the intervention (P = 0.029). The number of calls that were appropriately alerted to increased but was not significant (P = 0.120), whereas the degree of burnout from nonurgent calls remained relatively the same (P = 0.841).

CONCLUSIONS

The findings provide insight into the implementation of an EMR messaging system in an ED setting. These findings suggest the messaging system can decrease unnecessary nonurgent calls from registered nurses and medical doctors, allowing for more efficient workflow in the ED. These findings suggest further research especially regarding burnout implemented on a larger scale and yield redesign suggestions in the ED.

Frequency of Social Media and Digital Scholarship Keywords in U.S. Medical Schools' Promotion and Tenure Guidelines

PURPOSE

Medical schools must have clear policies and procedures for promotion and tenure (P&T) of faculty. Social media and digital scholarship (SMDS) is an emerging form of scholarship capable of reaching audiences quickly, conveniently, and in a wide variety of formats. It is unclear how frequently SMDS is considered during P&T reviews. The authors sought to determine whether current P&T guidelines at medical schools consider SMDS.

METHOD

The authors acquired P&T guidelines from any U.S. Liaison Committee on Medical Education-accredited medical school (or their governing university) that were available online between October and December 2020. Using an iterative process, they developed a bank of keywords that were specific to SMDS or that could include SMDS between October and December 2020. The authors searched each school's guidelines for each keyword and determined whether the word was being used in relation to crediting faculty for SMDS in the context of P&T procedures. The primary outcome measure was the dichotomous presence or absence of SMDS-specific keywords in each school's P&T guidelines.

RESULTS

The authors acquired P&T guidelines from 145/154 (94%) medical schools. After removing duplicate documents, the authors considered 139 guidelines. The keyword bank included 59 terms, of which 49 were specific to SMDS and 10 were umbrella terms that could be inclusive of SMDS. Of the 139 guidelines, 121 (87%) contained at least 1 SMDS-specific keyword. Schools had a median of 3 SMDS-specific keywords in their P&T guidelines.

CONCLUSIONS

As the presence and impact of SMDS increase, schools should provide guidance on its role in the P&T process. Faculty should receive clear guidance on how to document quality SMDS for their promotion file.

Evaluating Applicant Perceptions of the Impact of Social Media on the 2020-2021 Residency Application Cycle Occurring During the COVID-19 Pandemic: Survey Study

BACKGROUND

Due to challenges related to the COVID-19 pandemic, residency programs in the United States conducted virtual interviews during the 2020-2021 application season. As a result, programs and applicants may have relied more heavily on social media-based communication and dissemination of information.

OBJECTIVE

We sought to determine social media's impact on residency applicants during an entirely virtual application cycle.

METHODS

An anonymous electronic survey was distributed to 465 eligible 2021 Match applicants at 4 University of California Schools of Medicine in the United States.

RESULTS

A total of 72 participants (15.5% of eligible respondents), applying to 16 specialties, responded. Of those who responded, 53% (n=38) reported following prospective residency accounts on social media, and 89% (n=34) of those respondents were positively or negatively influenced by these accounts. The top three digital methods by which applicants sought information about residency programs included the program website, digital conversations with residents and fellows of that program, and Instagram. Among respondents, 53% (n=38) attended virtual information sessions for prospective programs. A minority of applicants (n=19, 26%) adjusted the number of programs they applied to based on information found on social media, with most (n=14, 74%) increasing the number of programs to which they applied. Survey respondents ranked social media's effectiveness in allowing applicants to learn about programs at 6.7 (SD 2.1) on a visual analogue scale from 1-10. Most applicants (n=61, 86%) felt that programs should use social media in future application cycles even if they are nonvirtual.

CONCLUSIONS

Social media appears to be an important tool for resident recruitment. Future studies should seek more information on its effect on later parts of the application cycle and the Match.

The Effects of Implementing a “Waterfall” Emergency Physician Attending Schedule

Introduction: Increases in emergency department (ED) crowding and boarding are a nationwide issue resulting in worsening patient care and throughput. To compensate, ED administrators often look to modifying staffing models to improve efficiencies. Methods: This study evaluates the impact of implementing the waterfall model of physician staffing on door-to-doctor time (DDOC), door-to-disposition time (DDIS), left without being seen (LWBS) rate, elopement rate, and the number of patient sign-outs. We examined 9,082 pre-intervention ED visits and 8,983 post-intervention ED visits. Results: The change in DDOC, LWBS rate, and elopement rate demonstrated statistically significant improvement from a mean of 65.1 to 35 minutes (P <0.001), 1.12% to 0.92% (P = 0.004), and 3.96% to 1.95% (P <0.001), respectively. The change in DDIS from 312 to 324.7 minutes was not statistically significant (P = 0.310). The number of patient sign-outs increased after the implementation of a waterfall schedule (P <0.001). Conclusion: Implementing a waterfall schedule improved DDOC time while decreasing the percentage of patients who LWBS and eloped. The DDIS and number of patient sign-outs appears to have increased post implementation, although this may have been confounded by the increase in patient volumes and ED boarding from the pre- to post-intervention period.

Triage physicians in an academic emergency department: Impact on resident education

BACKGROUND

Overcrowding in emergency departments (EDs) in the United States has been linked to worse patient outcomes. Implementation of countermeasures such as a physician-in-triage (PIT) system have improved patient care and decreased wait times. The purpose of this study was to evaluate how a PIT system affects medical resident education in an academic ED.

METHODS

This was a retrospective observational comparison of resident metrics at a single-site, urban, academic ED before and after implementing a PIT system. Resident metrics of average emergency severity index (ESI), patients-per-hour, and in-training-examination scores were measured before and six months after the implementation of the PIT system.

RESULTS

In total, 18,231 patients were evaluated by all residents in the study period before PIT implementation compared to 17,008 in the study period following PIT implementation. The average ESI among patients evaluated by residents decreased from 3.00 to 2.68 (p < 0.01, 95% confidence interval [CI] = 0.31 to 0.33), while average resident patient-per-hour rate decreased from 1.41 to 1.32 (p < 0.01, 95% CI = 0.05 to 0.13] and ITE scores saw no statistically significant change of 76.11 to 78.26 (p = 0.26, 95% CI = -5.75 to 1.45). While these differences are statistically significant, they are likely not clinically significant.

CONCLUSIONS

Our implementation of PIT system at one academic medical center minimally increased the acuity and minimally decreased the number of patients that residents see. This suggested that in our center, a PIT program did not detract from ED resident clinical education. However, further research with alternative markers in multiple centers is needed.

Accreditation Council for Graduate Medical Education Milestones for Emergency Medicine Residency Training Incorporated into First- and Second-Year Medical Student Elective

INTRODUCTION

As part of its Next Accreditation System, the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine describe 6 competencies containing 23 sub-competencies graded by milestones ranging from level 1 (expected of an incoming intern) to level 5 (demonstrates abilities of an attending) that are used to track resident training progression. To the best of our knowledge, there have been no studies introducing a milestones-based curriculum to medical students prior to their introduction to the wards, so we sought to determine the effects that a pre-clinical Emergency Medicine Interest Group (EMIG) Milestones Elective would have on preparing the students interested in Emergency Medicine (EM) as a specialty to meet the level 1 milestones prior to their intern year.

METHODS

The elective hosted 15 events throughout the academic year, and pre- and post-curriculum surveys were administered. Thirteen first- and second-year medical students at our institution who completed the elective self-reported their perception of preparedness for each level 1 milestone in the 19 sub-competencies. A repeated measures design was used through identical pre- and post-curriculum surveys to determine any changes in self-reported preparedness for meeting level 1 milestones after completing the elective using Wilcoxon Signed Ranks Test.

RESULTS

There was a significant increase in the median scoring from 1 to 2 (p=0.027) in overall self-reported preparedness for meeting the level 1 milestones included in the elective, as well as significant increases in subcategories across competencies 1-4 outlined by the ACGME. There was no significant increase in preparedness for professionalism or interpersonal communication competencies. There was no significant increase in interest in EM as a result of the elective.

CONCLUSION

Implementing a milestones-based curriculum during the pre-clinical years shows improved self-reported preparedness of students interested in pursuing EM for meeting level 1 milestones prior to residency. Additionally, a specialty-based elective such as this one offered through EMIG may further increase interest in the field during pre-clinical years.

Planning Engaging, Remote, Synchronous Didactics in the COVID-19 Pandemic Era

As part of the Accreditation Council for Graduate Medical Education requirements, residents must participate in structured didactic activities. Traditional didactics include lectures, grand rounds, simulations, case discussions, and other forms of in-person synchronous learning. The COVID-19 pandemic has made in-person activities less feasible, as many programs have been forced to transition to remote didactics. Educators must still achieve the goals and objectives of their didactic curriculum despite the new limitations on instructional strategies. There are several strategies that may be useful for organizing and creating a remote residency didactic curriculum. Educators must master new technology, be flexible and creative, and set rules of engagement for instructors and learners. Establishing best practices for remote didactics will result in successful, remote, synchronous didactics; reduce the impact of transitioning to a remote learning environment; and keep educators and learners safe as shelter-at-home orders remain in place.

Utilization of Educational Videos to Improve Communication and Discharge Instructions

Introduction

When discharging a patient from the emergency department (ED), it is crucial to make sure that they understand their disposition and aftercare instructions. However, numerous factors make it difficult to ensure that patients understand their next steps. Our objective was to determine whether patient understanding of ED discharge and aftercare instructions could be improved through instructional videos in addition to standard written discharge instructions.

Methods

This was a prospective pre- and post-intervention study conducted at a single-center, academic tertiary care ED. Patients presenting with the five selective chief complaints (closed head injury, vaginal bleeding, laceration care, splint care, and upper respiratory infection) were given questionnaires after their discharge instructions to test comprehension. Once video discharge instructions were implemented, patients received standard discharge instructions in addition to video discharge instructions and were given the same questionnaire. A total of 120 patients were enrolled in each group.

Results

There were significantly better survey scores after video discharge instructions (VDI) vs standard discharge instructions (SDI) for the closed head injury (27% SDI vs 46% VDI, P = 0.003); upper respiratory infection (28% SDI vs 64% VDI; P < 0.0001); and vaginal bleeding in early pregnancy groups (20% SDI vs 60% VDI, P < 0.0001). There were no significant differences in survey scores between the splint care (53% SDI vs 66% VDI; P = 0.08) and suture care groups (29% SDI vs 31% VDI; P = 0.40).

Conclusion

Video discharge instructions supplementing standard written instructions can help improve patient comprehension and information retention. This better understanding of aftercare instructions is essential to patient follow-up and has been shown to improve patient outcomes.

Patient Perception of Providers: Do Patients Understand Who Their Doctor Is?

Background:

When being treated at a university-based hospital, a patient may encounter multiple levels of physicians, including trainees during a single emergency visit. Patients want to know the roles of their providers, but their understanding of the medical education hierarchy is poor.

Objectives:

Our study explored patient understanding of commonly used physician and trainee titles as well as the factors that contribute to patient understanding in our emergency department patient population. Additionally, we evaluated a new badge buddy system that identifies medical personnel impacts patient’s perceptions of providers. We examined how the increasing prevalence of medicine in media may change patient perceptions of the medical hierarchy.

Methods:

Patients pending discharge from the emergency room was assessed through a knowledge-based and opinion-based questionnaire. Questions quantified the percentage of patients who understood titles of their team.

Results:

Of 423 patients who completed the study, 88% (N = 365) felt it was very important to know the level of training of their doctor when being treated in the emergency department. Seventy-four percent (N = 303) believed they knew the role of their care providers but the mean knowledge score was 4.7 of 8, suggesting a poor understanding of the medical training hierarchy. Younger patients and those who felt that knowing the level of training of their doctor was very important noticed the badge buddies more frequently (80.9%, P = .020 and 81%, P < .001).

Conclusions:

Our study found that patients had a poor understanding of the medical training hierarchy, but felt that it is important to know the level of training of their staff. The implementation of a badge buddy served this purpose for most patients, but was less effective for older patients. Further research may be needed to evaluate if a different intervention, such as a detailed video or teach-back techniques explaining the levels of medical training, would be more effective for a larger population of patients.

Which Applicant Factors Predict Success in Emergency Medicine Training Programs? A Scoping Review

BACKGROUND

Program directors (PDs) in emergency medicine (EM) receive an abundance of applications for very few residency training spots. It is unclear which selection strategies will yield the most successful residents. Many authors have attempted to determine which items in an applicant's file predict future performance in EM.

OBJECTIVES

The purpose of this scoping review is to examine the breadth of evidence related to the predictive value of selection factors for performance in EM residency.

METHODS

The authors systematically searched four databases and websites for peer-reviewed and gray literature related to EM admissions published between 1992 and February 2019. Two reviewers screened titles and abstracts for articles that met the inclusion criteria, according to the scoping review study protocol. The authors included studies if they specifically examined selection factors and whether those factors predicted performance in EM residency training in the United States.

RESULTS

After screening 23,243 records, the authors selected 60 for full review. From these, the authors selected 15 published manuscripts, one unpublished manuscript, and 11 abstracts for inclusion in the review. These studies examined the United States Medical Licensing Examination (USMLE), Standardized Letters of Evaluation, Medical Student Performance Evaluation, medical school attended, clerkship grades, membership in honor societies, and other less common factors and their association with future EM residency training performance.

CONCLUSIONS

The USMLE was the most common factor studied. It unreliably predicts clinical performance, but more reliably predicts performance on licensing examinations. All other factors were less commonly studied and, similar to the USMLE, yielded mixed results.

Not Another Boring Resident Didactic Conference

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) requires that residency programs in emergency medicine plan at least 5 hours of didactic experiences per week. Instructional methods should include small-group techniques, problem-based learning, or computer-based instruction. Despite recommendations from the ACGME, many programs' conference didactics continue to include primarily lecture-based instruction.

METHODS

The authors describe instructional methods that promote active learning and may be superior to traditional lecture-based education.

RESULTS

These methods include varying instructional methods, case-based learning, team-based learning and the flipped classroom, audience response systems, simulation, "wars," oral boards, escape rooms and scavenger hunts, expert panel discussions, debates, clinical pathologic cases, and leaderboards. The authors discuss how these methods can be implemented to make emergency medicine didactic conferences more varied and interactive for learners.

CONCLUSIONS

While there is minimal research on the efficacy of these methods in graduate medical education, many have shown to improvement engagement of learners and to be effective in undergraduate medical education. Further research will be needed to determine if long-term learning outcomes can be improved with these strategies.

Does Applicant Gender Have an Effect on Standardized Letters of Evaluation Obtained During Medical Student Emergency Medicine Rotations?

BACKGROUND

The standardized letter of evaluation (SLOE) in emergency medicine (EM) is one of the most important items in a student's application to EM residency and replaces narrative letters of recommendation. The SLOE ranks students into quantile categories in comparison to their peers for overall performance during an EM clerkship and for their expected rank list position. Gender differences exist in several assessment methods in undergraduate and graduate medical education. No authors have recently studied whether there are differences in the global assessment of men and women on the SLOE.

OBJECTIVES

The objective of this study was to determine if there is an effect of student gender on the outcome of a SLOE.

METHODS

This was a retrospective observational study examining SLOEs from applications to a large urban, academic EM residency program from 2015 to 2016. Composite scores (CSs), comparative rank scores (CRSs), and rank list position scores (RLPSs) on the SLOE were compared for female and male applicants using Mann-Whitney U-test.

RESULTS

From a total 1,408 applications, 1,038 applicants met inclusion criteria (74%). We analyzed 2,092 SLOEs from these applications. Female applicants were found to have slightly lower and thus better CRSs, RLPSs, and CSs than men. The mean CRS for women was 2.27 and 2.45 for men (p < 0.001); RLPS for women was 2.32 and 2.52 for men (p < 0.001) and CS was 4.59 for women and 4.97 for men (p < 0.001).

CONCLUSIONS

Female applicants have somewhat better performance on the EM SLOE than their male counterparts.

A Retrospective Cohort Study of the Effect of Home Institution on Emergency Medicine Standardized Letters of Evaluation

BACKGROUND

The standardized letter of evaluation (SLOE) was developed to make letters of recommendation in emergency medicine (EM) more objective and discerning. Typically, students obtain one SLOE from a home EM rotation and at least one more SLOE from an away clerkship. It is unclear if students perform better on their home or away EM rotations.

OBJECTIVE

The purpose of this study was to determine if students perform better on the group SLOE at their home institution compared to an away institution.

METHODS

The authors performed a retrospective application review of all allopathic applicants to an urban, academic EM residency program. The authors calculated a composite score (CS) for each group SLOE, using the global assessment scores for comparative rank and rank list position. A lower CS indicates better performance. The authors compared mean CS for students' first home rotations with first away rotations. For students in the study who had a third (second away or second home site) SLOE available, the authors compared mean CS on the students' first SLOEs with mean CS on the students' third SLOEs.

RESULTS

A total of 624 records were included in the primary analysis. There was a small, but significant difference between mean CS for students' home rotations when compared to away rotations (4.67 vs. 4.85, p = 0.024). Students performed better on their home rotations. Students who had three SLOEs available performed worse on their third rotation (first = 4.40, second = 4.63, third = 4.77, p = 0.012 for first vs. third). For all available SLOEs, more than 50% of students fell into the top 10% or top one-third categories.

CONCLUSION

Students perform slightly better on their home EM rotations. Students' mean SLOE CS is slightly worse for a third rotation when compared to a first rotation.

Comparison of the Bleeding Cricothyrotomy Model to SimMan for Training Students and Residents Emergency Cricothyrotomy

INTRODUCTION

A cricothyroidotomy is an emergency procedure that few emergency medicine residents see or perform during their training. Therefore, there is a need for low cost, high fidelity models for training. In this study, we explore a new training model for cricothyroidotomies (the bleeding CRIC [cost-effective realistic interactive cricothyroidotomy]) to determine if this new task-trainer is non-inferior compared to the current standard of training.

METHODS

Authors conducted a randomized control non-inferiority study. There were seventeen residents and medical students enrolled by convenience sample to partake in the study. The participants were randomized by block randomization to be taught how to perform a cricothyroidotomy on either the new task trainer or the current standard task trainer and then were asked to perform the procedure on a pig trachea model. Primary outcome measures were scores on a previously validated objective assessment tool and secondary outcomes were comfort levels and realism scores based on pre and post survey results which were analyzed with ANOVA.

RESULTS

There was found to be no statistically significant difference between the groups in assessment scores, time to completion, or comfort levels pre- and post-intervention. There was a statistically significant difference in that the participants gave higher realism scores in post-test analysis to the Bleeding CRIC compared to the SimMan. Both groups demonstrated that they had significantly improved comfort levels from baseline post-intervention.

CONCLUSION

Overall, the new task trainer was rated by learners to feel more realistic than the current standard. This study demonstrates non-inferiority of the new task trainer and further studies with larger sample sizes should be conducted to determine its true efficacy.

Emergency medicine residency fact board: Why our attempt to encourage on-shift learning failed

Residents commonly feel that a lack of time is a significant barrier in keeping up-to-date with both medical knowledge and literature. In this study, we addressed that barrier by placing an iPad-based live fact feed in the resident workroom of our emergency department, therefore allowing for passive learning while on shift. We hypothesized that residents with access to the live feed would score higher on monthly post-curriculum block exams. We ended up finding that the residents actually prefer a more active approach to learning and that many more people in the emergency department other than the residents benefitted from the fact board.

A Multiple-Mini Interview (MMI) for Emergency Medicine Residency Admissions: A Brief Report and Qualitative Analysis

INTRODUCTION

A multiple-mini interview (MMI) is a type of structured interview, which may assess many non-cognitive domains in residency applicants. There are few studies on MMI during the emergency medicine (EM) residency admissions process in the United States. We sought to determine the strengths, weaknesses, and acceptability of a pilot MMI for EM residency admissions.

METHODS

We piloted a five-station MMI with nine residency applicants. Following the MMI, we surveyed all participants, using 15 open- and closed-ended questions. Using grounded theory analysis, we coded the responses to the post-intervention survey to uncover the strengths and weaknesses of the MMI for EM residency admissions.

RESULTS

All nine students completed the survey. A positive theme that emerged from the survey was that the MMI was a positive, unexpected experience (all respondents, n=9). Candidates felt they were able to showcase unique talents, which would not be observed during a traditional interview (n=3). A negative theme that emerged from the survey was that the experience was intimidating (n=3). Candidates felt that the MMI left out important aspects of a typical interview day (n=3); such as, time for the candidate to become more familiar with the program.

CONCLUSIONS

An MMI may be a positive experience for candidates, but may also induce more anxiety. The MMI may omit an important piece of the interview day: an opportunity for the applicants to familiarize themselves with the residency program.

Efficacy of an asynchronous electronic curriculum in emergency medicine education in the United States

PURPOSE

The aim of this study was to measure the effect of an iPad-based asynchronous curriculum on emergency medicine resident performance on the in-training exam (ITE). We hypothesized that the implementation of an asynchronous curriculum (replacing 1 hour of weekly didactic time) would result in non-inferior ITE scores compared to the historical scores of residents who had participated in the traditional 5-hour weekly didactic curriculum.

METHODS

The study was a retrospective, non-inferiority study. conducted at the University of California, Irvine Emergency Medicine Residency Program. We compared ITE scores from 2012 and 2013, when there were 5 weekly hours of didactic content, with scores from 2014 and 2015, when 1 hour of conference was replaced with asynchro-nous content. Examination results were compared using a non-inferiority data analysis with a 10% margin of difference.

RESULTS

Using a non-inferiority test with a 95% confidence interval, there was no difference between the 2 groups (before and after implementation of asynchronous learning), as the confidence interval for the change of the ITE was -3.5 to 2.3 points, whereas the 10% non-inferiority margin was 7.8 points.

CONCLUSION

Replacing 1 hour of didactic conference with asynchronous learning showed no negative impact on resident ITE scores.

Who to Interview? Low Adherence by U.S. Medical Schools to Medical Student Performance Evaluation Format Makes Resident Selection Difficult

Introduction

The Medical Student Performance Evaluation (MSPE) appendices provide a program director with comparative performance for a student’s academic and professional attributes, but they are frequently absent or incomplete.

Methods

We reviewed MSPEs from applicants to our emergency medicine residency program from 134 of 136 (99%) U.S. allopathic medical schools, over two application cycles (2012–13, 2014–15). We determined the degree of compliance with each of the five recommended MSPE appendices.

Results

Only three (2%) medical schools were compliant with all five appendices. The medical school information page (MSIP, appendix E) was present most commonly (85%), followed by comparative clerkship performance (appendix B, 82%), overall performance (appendix D, 59%), preclinical performance (appendix A, 57%), and professional attributes (appendix C, 18%). Few schools (7%) provided student-specific, comparative professionalism assessments.

Conclusion

Medical schools inconsistently provide graphic, comparative data for their students in the MSPE. Although program directors (PD) value evidence of an applicant’s professionalism when selecting residents, medical schools rarely provide such useful, comparative professionalism data in their MSPEs. As PDs seek to evaluate applicants based on academic performance and professionalism, rather than standardized testing alone, medical schools must make MSPEs more consistent, objective, and comparative.