Jennifer Mitzman

Background: The American Board of Emergency Medicine (ABEM) has recently introduced a new Certifying Exam, which incorporates assessment of performance in a simulated clinical environment. Simulation‐based assessments allow for reproducible, controlled evaluations. The residency program has a responsibility to prepare residents for the Certifying Exam and to verify resident competency. We sought to determine the feasibility of a simulation‐based assessment program encompassing three domains (resuscitation, procedural skills, and communication) with assessments against pre‐determined Minimum Competency Scores (MCS) to provide evidence for program director attestations of competence. Methods: Eight stations were chosen based on ABEM's Certifying Exam content, the Accreditation Council for Graduate Medical Education (ACGME) Milestones, and proposed Entrustable Professional Activities. Simulation‐based case scenarios and assessment checklists were created with standard settings performed using the Mastery Angoff process. These stations were categorized into three different domains: resuscitation (Adult Medical, Pediatric Medical, Trauma, and Neonatal), procedural skills (Direct Laryngoscopy, Cricothyrotomy, and Central Venous Catheter Placement), and communication (Breaking Bad News). Results were summarized with descriptive statistics. Results: Thirty emergency medicine residents at an academic Midwestern residency program underwent assessments over one year. None of the residents achieved the MCS on all eight assessments. Residents achieved the MCS on an average of 4.24 stations. There was large performance variability, particularly for the Pediatric Medical (27%–100% items correct), Neonatal Resuscitation (30%–100%), and Breaking Bad News (31%–100%) scenarios. A greater percentage of residents met the MCS for procedural assessments. Conclusions: This pilot study demonstrated the feasibility of a simulation‐based assessment program designed to provide objective evidence of clinical competency. Assessment outcomes and associated feedback can be used by learners to guide the development of educational plans for performance improvement. Educators can use the resulting data to assess readiness for independent practice, prepare for the Certifying Exam, and identify content areas that may require additional program‐wide education.

Objective: Pediatric emergency medicine (PEM) fellowship directors can interview candidates from either pediatric or EM residency programs. Currently, most candidates are pediatricians; however, because emergency physicians have attributes that could benefit PEM, our goal was to investigate facilitators and barriers to training more of them to become PEM physicians.Methods: We surveyed U.S. PEM fellowship program directors (PDs) about their program's recruitment practices: Do they recruit only pediatricians or mostly pediatricians with an occasional emergency physician or do they actively recruit both? We solicited volunteers from each recruitment group for interviews. These were recorded, transcribed, and thematically coded using summative content analysis. Comments were cataloged into themes that were philosophical or logistic in nature and those that might facilitate (drivers) or serve as barriers (restrainers) to the inclusion of emergency physicians in PEM.Results: We received 50 of 86 (58%) survey responses, 29 (34%) of whom volunteered for interviews. The 17 volunteers we selected for interviews generated 13 themes that fell into the four major theme categories: four philosophical drivers, three logistic drivers, two philosophical restrainers, and four logistic restrainers. Program groups differed with regard to the inclusion of emergency physicians. Most limiting were the impact of variable program length and the implicit belief that pediatricians are best suited to treat children. Most beneficial is the recognized value of EM graduates to the field of PEM.Conclusions: While PDs acknowledged a growing need for PEM physicians, particularly in community hospitals, and that emergency physicians would contribute to PEM, they also identified the logistical burden of including them in programs primarily designed for pediatricians. This burden involves maintaining separate curricula for EM graduates and finding emergency physician faculty to serve as mentors. PDs also expressed a desire for resources to guide the integration of more emergency physicians into their programs.

Objectives: Pediatric emergency medicine (PEM) fellows are expected to perform high-risk procedures across a wide range of patient age, size, and physiology including procedures that are no longer required during pediatric residency training. Examples include central venous catheter (CVC) placement, endotracheal intubation of children and adolescents, and tube thoracostomy placement. Simulation-based mastery learning has demonstrated decreased patient morbidity. In this study, we describe implementation of a simulation-based mastery learning (SBML) procedural curriculum for PEM fellows. Methods: Our PEM fellows underwent an SBML procedural curriculum for lumbar puncture (LP), CVC placement, endotracheal intubation, and tube thoracostomy placement. These procedures are mandatory for fellows to learn, have known association with potential iatrogenic injury, and are widely available commercial task trainers. Fellows underwent baseline assessments, group demonstration, deliberate practice, and then postassessments. For both pre- and postassessments, we used internally developed checklists with minimum passing scores (MPSs) calculated by the Mastery-Angoff technique. Results: Nineteen pediatrics residency-trained PEM fellows underwent this curriculum over a 2-year period. Six fellows (31.58%) achieved the MPS on all four procedures during their first posttest attempt. All fellows achieved the MPS on all four procedures by the second posttest attempt. Most fellows (17/19 or 89.47%) did not achieve the MPS on baseline LP assessments, despite inclusion of this procedure as an Accreditation Council of Graduate Medical Education (ACGME) requirement during their pediatric residency training. Conclusions: All participating PEM fellows demonstrated competency after training on four procedures associated with iatrogenic injuries. Using an SBML framework is a feasible method to teach procedural skills to PEM fellows, allowing them to demonstrate objective measures of competency in the simulation laboratory.

Between 2008 and 2016, 23% of pregnancy-related deaths in Ohio occurred in an emergency department (ED) or outpatient setting. Prior research showed that 98% of Ohio's delivery hospitals conduct obstetric (OB) emergency simulations, whereas only 30% include ED staff. The goal of the grant was to increase the knowledge, skill, and self-efficacy of emergency medicine (EM) professionals in managing OB emergencies. In addition to EM professionals, there was high interest by obstetrics and gynecology (OB/GYN) and other professionals in the course. Therefore, the goal of the project was to increase these elements for all professionals including EM and non-EM professionals in managing OB emergencies.Twelve virtual training courses using simulated patient encounters and video-based skills training were conducted across Ohio on the management of OB emergencies. Scenarios focused on common causes of pregnancy-related death using data from the Ohio Pregnancy-Associated Mortality Review Committee. Pre- and posttests assessed training effectiveness.Between August 1, 2020, and June 30, 2023, 258 learners completed the course. Most were female (76.76%), White (90.61%), and under 45 years old (69.40%). Most (66.49%) were from EM, followed by OB/GYN (18.09%), and other specialties (15.43%) including family medicine and pediatric EM. Most worked in hospital settings (89.19%). Learners reported a median 10.00 (interquartile range [IQR]: 15.00) years in clinical practice. Overall, mean knowledge scores increased by 0.81 (95% confidence interval [CI]: 0.62, 1.01), after the course (p < 0.001). Mean knowledge scores increased by 0.90 (95% CI: 0.64, 1.16; p < 0.001), 0.67 (95% CI: 0.24, 1.09; p = 0.003), and 0.60 (95% CI: 0.16, 1.04; p = 0.01) for those from EM, OB/GYN, and other specialties, respectively. Median scores for reported self-efficacy increased by 24.00 (IQR: 22.33) and self-reported skills increased by 30.42 (IQR: 22.83) points (p < 0.001).Virtual simulations can be effective in improving EM, OB, and other professionals' knowledge, self-efficacy, and self-reported skills in managing OB emergencies.

Introduction: Despite the increasing diversity of individuals entering medicine, physicians from racial and sexual minority groups continue to experience bias and discrimination in the workplace. The objective of this study was to determine the current experiences and perceptions of discrimination on the basis of race and sexual orientation among academic emergency medicine (EM) faculty.Methods: We conducted a cross-sectional survey of a convenience sample of EM faculty across six programs. Survey items included the Overt Gender Discrimination at Work (OGDW) Scale adapted for race and sexual orientation, and the frequency and source of experienced and observed discrimination. Group comparisons were made using t-tests or chi-square analyses, and relationships between race or sexual orientation, and we evaluated physicians’ experiences using correlation analyses.Results: A total of 141 out of 352 (40.1%) subjects completed at least a portion of the survey. Non-White physicians reported higher mean racial OGDW scores than their White counterparts (13.4 vs 8.6; 95% confidence interval (CI) for difference, -7.7 – -2.9). Non-White EM faculty were also more likely to report having experienced discriminatory treatment based on race than were White EM faculty (48.0% vs 12.6%; CI for difference, 16.6% – 54.2%), although both groups were equally likely to report having observed race-based discrimination of another physician. EM faculty who identified as sexual minorities reported higher mean sexual minority OGDW scores than their heterosexual counterparts (11.1 vs 7.1; 95% CI for difference, -7.3 – -0.6). There were no significant differences between sexual minority and heterosexual faculty in their reports of experiencing or observing discrimination based on sexual orientation.Conclusion: EM faculty from racial and sexual minority groups perceived more discrimination based on race or sexual orientation in their workplace than their majority counterparts. EM faculty regardless of race or sexual orientation were similar in their observations of discriminatory treatment of another physician based on race or sexual orientation.

Introduction: Gender-based discrimination and sexual harassment of female physicians are well documented. The #MeToo movement has brought renewed attention to these problems. This study examined academic emergency physicians’ experiences with workplace gender discrimination and sexual harassment.Methods: We conducted a cross-sectional survey of a convenience sample of emergency medicine (EM) faculty across six programs. Survey items included the following: the Overt Gender Discrimination at Work (OGDW) Scale; the frequency and source of experienced and observed discrimination; and whether subjects had encountered unwanted sexual behaviors by a work superior or colleague in their careers. For the latter question, we asked subjects to characterize the behaviors and whether those experiences had a negative effect on their self-confidence and career advancement. We made group comparisons using t-tests or chi-square analyses, and evaluated relationships between gender and physicians’ experiences using correlation analyses.Results: A total of 141 out of 352 (40.1%) subjects completed at least a portion of the survey. Women reported higher mean OGDW scores than men (15.4 vs 10.2; 95% confidence interval [CI], 3.6–6.8). Female faculty were also more likely to report having experienced gender-based discriminatory treatment than male faculty (62.7% vs 12.5%; 95% CI, 35.1%-65.4%), although male and female faculty were equally likely to report having observed gender-based discriminatory treatment of another physician (64.7% vs 56.3%; 95% CI, 8.6%-25.5%). The three most frequent sources of experienced or observed gender-based discriminatory treatment were patients, consulting or admitting physicians, and nursing staff. The majority of women reported having encountered unwanted sexual behaviors in their careers, with a significantly greater proportion of women reporting them compared to men (52.9% vs 26.2%, 95% CI, 9.9%-43.4%). The majority of unwanted behaviors were sexist remarks and sexual advances. Of those respondents who encountered these unwanted behaviors, 22.9% and 12.5% reported at least somewhat negative effects on their self-confidence and career advancement.Conclusion: Female EM faculty perceived more gender-based discrimination in their workplaces than their male counterparts. The majority of female and approximately a quarter of male EM faculty encountered unwanted sexual behaviors in their careers.

For many emergency medicine (EM) residency programs, pediatric education takes place at independent pediatric emergency departments (PEDs). Residency programs are charged with selecting a scheduling model for their residents' clinical experience at these PEDs. The main advantage of block scheduling is that it immerses the residents in pediatric care for a period of time and provides continuity of work with the same PED attending faculty. The longitudinal model offers residents continuous pediatrics experience throughout their training and allows them to treat illnesses related to the seasons (seasonal variation). The purpose of this project was to evaluate a shift from block to longitudinal scheduling through the eyes of the PED attending faculty members. A questionnaire was designed by a committee to obtain attending faculty's opinions about resident scheduling, seasonality, and the factors they would consider to make decisions about resident autonomy in patient care. The questionnaire was reviewed by a survey expert and piloted; they were then delivered electronically to 60 faculty members at our affiliated children’s hospital emergency department (ED). The survey return rate was 63%. Most attending faculty expressed a preference for longitudinal over block scheduling because it eliminated the negative impact of seasonality on resident education. Others expressed positive features, including more sustained experience with pediatrics throughout training, and an experience that was more representative of day-to-day emergency medicine practice. A few attending faculty expressed concern that longitudinal scheduling would jeopardize attending faculty's familiarity with residents, making it difficult for residents to be entrusted to work autonomously. Most of the attending faculty suggested that their familiarity with a resident was a key factor in how they made decisions about the resident’s participation in procedures or resident autonomy; however, very few were concerned that longitudinal scheduling would impact their ability to “get to know a resident.” Attending faculty mostly thought that longitudinal scheduling was better than block scheduling. While they acknowledged that their familiarity with the resident was the driver of faculty entrustment in the PED, they did not express any concern that the scheduling change would affect their ability to get to know the residents. Other solutions, including a mixed scheduling model to address both issues, are also proposed.

The ability to teach in the clinical setting is of paramount importance. Clinical teaching is at the heart of medical education, irrespective of the learner’s level of training. Learners desire and need effective, competent, and thoughtful clinical teaching from their instructors. However, many clinician-educators lack formal training on this important skill and thus may provide a variable experience to their learners. Although formal training of clinician-educators is standard and required in many other countries, the United States has yet to follow suit, leaving many faculty members to fend for themselves to learn these important skills. In September 2018, the Academic Life in Emergency Medicine (ALiEM) 2018-2019 Faculty Incubator program discussed the topic of clinical teaching techniques. We gathered the titles of papers that were cited, shared, and recommended within our online discussion forum and compiled the articles pertaining to the topic of clinical teaching techniques. To augment the list, the authors did a formal literature search using the search terms “teaching techniques", "clinical teaching", "medical education", "medical students", and "residents” on Google Scholar and PubMed. Finally, we posted a call for important papers on the topic of clinical teaching techniques on Twitter. Through this process, we identified 48 core articles on the topic of clinical teaching. We conducted a modified Delphi methodology to identify the key papers on the topic. In this paper, we present the five highest-rated articles based on the relevance to junior faculty and faculty developers. This article will review and summarize the articles we found to be the most impactful to improve one’s clinical teaching skills.

Second victim syndrome (SVS) is defined as the psychological or emotional suffering of healthcare workers as a result of a patient adverse, or near miss, event. Initially thought to be related to medical error, we now recognize that SVS can result from a much wider range of circumstances including adverse pediatric patient events, unanticipated deaths, or patients well known to the provider. Residents are particularly susceptible to SVS yet relatively little is written about this topic targeted at their educators. Since educators are positioned to help recognize and guide learners through the experience, this paper targets that reader audience. In this article, we identify and summarize five key papers relevant to educators interested in learning more about SVS as it relates to learners. We identified an extensive list of papers relevant to SVS via online discussions within the Academic Life in Emergency Medicine (ALiEM) Faculty Incubator. The Faculty Incubator is a digital community of practice providing professional development for educators. This list was augmented by an open call on Twitter seen by over 2000 people and yielding a list of 31 papers. We then conducted a three-round modified Delphi process within the authorship group, which included both junior and senior clinician educators, to identify the most impactful papers for educators interested in SVS. The three-round modified Delphi process ranked all papers submitted for review and used iterative rounds to select the five highest-rated papers for inclusion in this article. The group then summarized each of the five papers with specific consideration for junior faculty educators and faculty developers with an interest in SVS in learners. The five papers featured in this article serve as a key reading list for educators across specialties interested in SVS and our commentary provides context for medical educators using the articles.