A lot on their plates? Examining the on-shift eating and drinking habits of Canadian emergency medicine physicians.

The use of etomidate as an induction agent for critically ill patients is controversial. While its favorable hemodynamic profile is enviable, etomidate has been shown to cause transient adrenal suppression. The clinical consequences of transient adrenal suppression are poorly understood. Anecdotally, some clinicians advocate strongly for etomidate, while others feel it can cause significant harm. To better understand the current clinical environment with respect to single-dose etomidate use in critically ill patients, Canadian anesthesiologists and Canadian emergency medicine (EM) physicians were questioned regarding their opinions, knowledge, and preferences about etomidate use as an induction agent. Invitations to participate with the electronic survey were sent to 100 Canadian EM physicians and 260 Canadian anesthesiologists. The survey had 4 general parts: demographics, familiarity with the current literature, choice of induction agent given various clinical scenarios, and opinions on the controversy. The Pearson γ2 test was used to detect whether significant differences exist between physician groups. Ninety three anesthesiologists and 42 EM physicians responded for response rates of 36% and 42%. There were no self-reported differences in knowledge about etomidate properties between EM physicians and anesthesiologists. There were significant differences in etomidate use between EM physicians and anesthesiologists in general rapid sequence intubation, noncritically ill patients, and those with undifferentiated hypotension. Both EM physicians and anesthesiologists describe the current etomidate controversy as significant and not adequately resolved. There is no significant difference in self-reported etomidate knowledge between anesthesiologists and EM physicians; however, significant practice pattern differences exist with EM physicians using etomidate more often. Broad agreement supports future research to investigate etomidate's impact in critically ill patients.

The HINTS examination (head impulse, nystagmus, test of skew) is a bedside physical examination technique that can distinguish between vertigo due to stroke, and more benign peripheral vestibulopathies. Uptake of this examination is low among Emergency Medicine (EM) physicians; therefore, we surveyed Canadian EM physicians to determine when the HINTS exam is employed, and what factors account for its low uptake. We designed and tested a 26-question online survey, and disseminated it via email to EM physicians registered with the Canadian Association of Emergency Physicians (CAEP), with 3 and 5-week reminder emails to increase completion. This anonymous survey had no incentives for participation, and was completed by 185 EM physicians, with post-graduate medical training in either Emergency Medicine or Family Medicine. The primary outcomes were the frequencies of various responses to survey questions, with secondary outcomes being the associations between participant characteristics and given responses. 88 respondents (47.8%) consistently use the HINTS examination in the work-up of vertigo, and 117 (63.7%) employ it in scenarios where its clinical utility is limited. The latter is more common among physicians working in non-academic settings, without 5-year EM residency training, and with greater years of practice (p < 0.01). The most frequent explanations for non-use were a lack of need for the HINTS examination, the lack of validation of the exam among EM physicians, and concerns surrounding the head-impulse test. Though HINTS exam usage is common, there is a need for education on when to apply it, and how to do so, particularly as concerns the head-impulse test. Our attached rubric may assist with this, but quality-improvement initiatives are warranted. Low uptake is partly due to the lack of validation of this examination among EM physicians, so effort should be made to conduct well-designed HINTS trials exclusively involving EM physicians.

Physicians working in the emergency department (ED) will interact with two-spirited, lesbian, gay, bisexual, transgender, queer/questioning and intersex (2SLGBTQI+) persons as colleagues and patients. These patients have unique healthcare needs and encounter negative experiences when seeking medical care, leading to poorer health outcomes and inequities. This study aims to explore the attitudes, behaviour, and comfort of Canadian emergency medicine (EM) physicians in caring for 2SLGBTQI+ patients. An anonymous survey was distributed to EM staff physicians and residents through the Canadian Association of Emergency Physicians (CAEP) network and social media channels. Demographic information was collected, and participants were asked about their comfort, current knowledge, and desire to gain new knowledge in caring for 2SLGBTQI+ patients. Personal perceptions and practice patterns in treating cisgender heterosexual (cis-het) and 2SLGBTQI+ patients were analysed using five-point Likert scales. Residents were asked additional questions regarding availability of learning experiences during training. 266 surveys were included in the final analysis consisting of 229 (86%) staff physicians and 37 (14%) residents. 97% (n = 258) of all respondents believed 2SLGBTQI+ patients deserve the same quality care from medical institutions as other patients. Further, 83% (n = 221) respondents agreed that they would like to increase their knowledge in taking care of 2SLGBTQI+ patients, while 34% (n = 91) agreed that performing physical examinations on transgender or intersex patients was more challenging than on cis-het patients. Among resident respondents, 46% indicated a lack of didactic teaching devoted to 2SLGBTQI+ care during residency (n = 17/37), while 38% encountered discrimination towards 2SLGBTQI+ patients, with most comments from senior faculty and nursing staff. This study suggests that Canadian EM physicians feel that 2SLGBTQI+ patients deserve equitable care when compared to cis-het patients. Future work should focus on educational needs and curricular enhancements in residency programs and continuing professional development for physicians to improve care for 2SLGBTQI+ patients in the ED.

Introduction: Dental complaints and emergencies are a common emergency department (ED) issue that has not been extensively studied. This study aimed to provide an evaluation of Canadian practice patterns and clinical training relating to dental emergencies in the ED. Methods: We conducted an electronic survey inviting 1520 Canadian emergency medicine (EM) physicians from CAEP’s physician distribution network. Thirty-three questions were asked regarding ED physician training with dental emergencies, practice patterns and comfort with dental care, current available ED dental resources, and how dental care may be improved in Canadian EDs. Standard descriptive statistics were calculated. Results: Survey response rate was 15.1%. Respondents were predominantly male (62.8%) with a mean 15.3 years (SD: ±9.8) of practice, and were primarily CCFP-EM (50.7%) or FRCP-trained (25.6%) in either tertiary (48.0%) or community (36.3%) teaching hospitals. They received broad training on dental issues, but this was limited in scope to ≤1 day of residency (61.4%). A combined majority (59.6%) felt their residency left them somewhat to very unprepared for treating dental complaints, and &amp;lt;40% of physicians reported feeling comfortable with specific, common dental emergency procedures, with the exception of avulsed tooth storage (61.1%). For pain management and local trauma exploration, 36.9% felt somewhat to very uncomfortable performing oral and facial nerve blocks. Many respondents do not have access to any dental emergency supplies (48.0%), or do not know if they have any access (14.2%). Furthermore, 18.9% have no access to any professional support for help with dental emergencies requiring advanced management. Respondents believe dental emergency consultant support is an issue at their centre (62.5%). EM physicians want more training with dental emergencies (79.5%) and improved access to dental-specific emergency materials in their departments (63.7%). The greatest barriers to providing good ED dental care were cost to patients (72.7%), physician comfort treating complaints (54.7%), and clear follow-up with outpatient dental professionals (54.3%). Conclusion: ED physicians feel relatively unprepared by their residency training to treat dental complaints, and professional dental support is an issue in the majority of EDs. Dental care may be improved with more access to training, to dental ED resources and professional support.

An increase in physical activity has been shown to improve outcomes in many diseases. An estimated 600 000 Canadians receive their primary health care from emergency departments (ED). This study aims to examine physical activity prescription by emergency medicine physicians (EPs) to determine factors that influence decisions to prescribe physical activity. A survey was distributed to EPs via email using the Canadian Association of Emergency Physicians (CAEP) survey distribution protocol. Responses from 20% (n = 332) of emergency physician/residents in Canada were analyzed. Of the EPs, 62.7% often/always counsel patients about preventative medicine (smoking, diet, and alcohol). Only 12.7% (42) often/always prescribe physical activity. The CCFP-trained physicians (College of Family Physicians Canada) were significantly more likely to feel comfortable than CCFP-EM-trained physicians (Family Physicians with Enhanced Skills in Emergency Medicine) prescribing physical activity (p = 0.0001). Both were significantly more likely than the FRCPC-trained EPs (Fellows of the Royal College of Physicians of Canada). Of the EPs, 73.4% (244) believe the ED environment does not allow adequate time for physical activity prescription. Family medicine-trained EPs are more likely to prescribe physical activity; the training they receive may better educate them compared with FRCPC-trained emergency medicine. Further education is required to standardize an approach to ED physical activity prescription.

Reworking Emergency Medicine Resident Education Post-Dobbs v Jackson Women's Health Organization.

There is an apparent conflict between published evidence and UK emergency medicine (EM) physician practice with regard to the use of intravenous fluids to treat patients intoxicated with alcohol. We conducted a survey of all EM physicians in North East (NE) England to determine opinion with regard to this therapy, and compared this with the available evidence for its benefit. We identified 136 EM consultants and trainees in NE England. Each one was contacted and asked to complete a questionnaire with regard to their opinion on the use of intravenous fluids for intoxicated patients, both with and without head injury. The majority (73%) of EM physicians in the NE England use intravenous fluids in their treatment of intoxicated patients. The treatment used varies, but the most commonly used fluid is 0.9% saline (volume range, 500-3000 ml; mean, 1300 ml). Fewer respondents (52%) would use intravenous fluids if the patient had suffered an apparent head injury. The use of intravenous fluids to treat intoxication is common practice among EM physicians in NE England. The available literature states that this practice is futile. However, there are significant limitations in these studies. This suggests that EM physicians might be using intravenous fluids therapy (IVT) because they are finding in their own practice it is effective. We hypothesize that IVT should improve care in most intoxicated patients as the result of a direct dilutional effect. Further research is required to establish the validity of existing EM physician's practice of using IVT.

Fluid volume measurement in the emergency department and intensive care unit (ICU) is critical for patient care. This study aimed to assess the knowledge of volume assessment among emergency medicine (EM) and ICU physicians in Saudi Arabia. A cross-sectional study was conducted among EMand ICU physicians using an online questionnaire. Data were collected on participants' demographics, work-related information, confidence in volume assessment, use of point-of-care ultrasonography, and knowledge and practices of volume assessment. Of the 114 physicians surveyed, 92 (80.7%) were aged 25-35 years, 65 (57%) were male, 70 (61.4%) were EM physicians, and 68 (59.6%) had fewer than five years of practice. ICU physicians demonstrated significantly higher knowledge that, in mechanically ventilated patients, a distensibility index of >18% indicates fluid responsiveness. In contrast, EM physicians had a higher proportion of correct responses regarding the indications for using Swan-Ganz catheters. The most commonly used method for volume assessment was physical examination (83, 72.8%), and the most frequently used laboratory biomarker was serum lactate (65, 57%). The majority (85, 74.6%) used focused cardiac assessments, including evaluation of the inferior vena cava, for volume assessment. ICU physicians reported significantly higher use of Doppler ultrasound for volume assessment. Only 17 (14.9%) physicians demonstrated a good level of knowledge of volume assessment, with no significant associations found between knowledge level and participants' demographics, work experience, or confidence in volume assessment. A poor understanding of fluid volume assessment was observed among EM and ICU physicians in Saudi Arabia. Training on the principles of volume assessment is needed.

Conventional wisdom suggests that in almost every profession, the most experienced and educated employees are remunerated at a higher rate than the less experienced ones. For example, new-graduate hires most commonly start at the bottom of the pay scale. No profession could reflect the importance of experience and the need for mastery of skills more than emergency medicine (EM), where a split-second decision could mean the difference between life and death. In Canada, however, EM physicians are remunerated as per a common pay scale that does not consider the length of their education, training, or years of practice. Such an unfair experience-remuneration mismatch (E-R mismatch) could lead to job dissatisfaction, burnout, and switching to other specialties. Given the current EM physician shortage in Canada, the E-R mismatch among such physicians could negatively impact patient care and the health system as a whole and prolong the already long wait times. The aim of this editorial is to shed light on this flaw in the Canadian healthcare system and lead to change toward a fair pay system. The creation of a professional and experience-based hierarchy among Canadian EM physicians should be considered a matter of urgency for those developing health-related legislation.

<h3>ABSTRACT</h3> <h3>Introduction</h3> Emergency care (EC) capacity is limited by physician shortages in low- and middle-income countries like Uganda. Task-sharing — delegating tasks to more narrowly trained cadres — including EC nonphysician clinicians (NPCs) is a proposed solution. However, little data exists to guide emergency medicine (EM) physician supervision of NPCs. This study’s objective was to assess the mortality impact of decreasing EM physician supervision of EC NPCs. <h3>Methods</h3> Retrospective analysis of prospectively collected data from an EC NPC training program in rural Uganda included three cohorts: “Direct” (2009-2010): EM physicians supervised all NPC care; “Indirect” (2010-2015): NPCs consulted EM physicians on an ad hoc basis; “Independent” (2015-2019): NPC care without EM physician supervision. Multivariable logistic regression analysis of three-day mortality included demographics, vital signs, co-morbidities and supervision. Sensitivity analysis stratified patients by numbers of abnormal vital signs. <h3>Results</h3> Overall, 38,344 ED visits met inclusion criteria. From the “Direct” to the “Unsupervised” period patients with ≥3 abnormal vitals (25.2% to 10.2%, p&lt;0.001) and overall mortality (3.8% to 2.7%, p&lt;0.001) decreased significantly. “Indirect” and “Independent” supervision were independently associated with increased mortality compared to “Direct” supervision (“Indirect” Odds Ratio (OR)=1.49 [95%CI 1.07 - 2.09], “Independent” OR=1.76 [95%CI 1.09 - 2.86]). The 86.2% of patients with zero, one or two abnormal vitals had similar mortality across cohorts, but the 13.8% of patients with ≥3 abnormal vitals had significantly reduced mortality with “Direct” supervision (“Indirect” OR=1.75 [95%CI 1.08 - 2.85], “Independent” (OR=2.14 [95%CI 1.05 - 4.34]). <h3>Conclusion</h3> “Direct” EM physician supervision of NPC care significantly reduced overall mortality as the highest risk ∼10% of patients had nearly 50% reduction in mortality. However, for the other ∼90% of ED visits, independent EC NPC care had similar mortality outcomes as directly supervised care, suggesting a synergistic model could address current staffing shortages limiting EC access and quality. <h3>SUMMARY BOX</h3> <h3>What is already known?</h3> Physician shortages and lack of specialty training limit implementation of emergency care and associated reductions in mortality in low- and middle-income countries (LMIC) such as Uganda. Task-sharing, often to non-physician clinicians, is proposed as a solution however data to support safe, effective training and physician supervision protocols is limited. <h3>What are the new findings?</h3> The highest risk 10% of emergency care patients have approximately a 50% reduction in mortality when non-physician clinicians are directly supervised by emergency medicine physicians. For most emergency care patients (the lowest risk 90%) independent emergency care by non-physician clinicians provides similar morality outcomes to direct supervision by an emergency medicine physician. <h3>What do the new findings imply?</h3> Training of both emergency care physicians and non-physician clinicians is essential, as physicians provide improved mortality outcomes, especially for the critically ill, and non-physician clinicians will help address lack of trained and available emergency care providers in a timely, cost-effective manner. Physician supervision of all emergency care is the penultimate goal, however non-physician clinicians can be trained to provide comparable morality outcomes for the vast majority of patients when practicing independently. Triage protocols are needed to identify high-risk emergency care patients, such as those with 3 or more abnormal vital signs, for early involvement of an emergency physician either directly, or through supervision of a non-physician clinician.

Few studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents. A team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs. Surveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED). Important barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.

The role of Prehospital Medical Directors is pivotal in military medicine, integrating emergency medical services within the military's trauma system, particularly within the framework of Large-Scale Combat Operations (LSCO). This study aims to explore the impact of the current training variability among emergency medicine (EM) physicians, the only physicians required to receive any Emergency Medical Services (EMS) training in residency and thus the current gold standard, on their ability to effectively manage and direct medical operations in LSCO scenarios. The study focuses on understanding the training needs, leveraging technological advances, and adapting to high-intensity military medical operations. This cross-sectional study was approved by the Institutional Review Board of the Uniformed Services University of the Health Sciences. Data were collected using an online survey disseminated via Qualtrics XM Platform to active-duty EM physicians across U.S. military branches. The survey, which remained open from January 1, 2024 to September 30, 2024, evaluated the training, experience, and comfort levels of respondents in providing medical direction. Statistical analysis involved descriptive statistics, independent t-tests, and analysis of variance to identify significant disparities in training outcomes. The survey yielded responses from 139 EM physicians, revealing significant variability in EMS training across residency programs. Results demonstrate that physicians who had received a crash course reported consistently higher comfort levels in performing critical medical direction tasks. Specifically, these physicians reported greater proficiency in teaching medics (74.7 ± 13.6 vs. 67.9 ± 25.0, P = .0326), establishing protocols (76.9 ± 17.3 vs. 63.4 ± 27.6, P = .0079), providing QA/QI feedback (74.2 ± 17.7 vs. 66.6 ± 27.8, P = .0549), and guiding complicated resuscitations (77.3 ± 15.3 vs. 65.3 ± 28.6, P = .0087) and procedures over the radio (74.3 ± 19.4 vs. 64.2 ± 27.6, P = .0373) compared to the respondents without training outside of residency. Conversely, physicians without supplementary training and no practical exposure reported the lowest self-perceived proficiency, particularly in high-stakes LSCO scenarios. The study confirms a critical gap in the preparedness of EM physicians to serve as Medical Directors in LSCO, largely because of inconsistent EMS training during residency. These findings underscore the "Walker Dip" phenomenon-an observed decline in casualty survival rates when transitioning from peacetime to initial conflict phases due to inadequate medical service adaptation. The results support the need for standardized, comprehensive training programs that incorporate Tactical Combat Casualty Care principles, advanced decision-making skills, and the use of modern technology for remote medical direction. Addressing these training disparities can enhance the operational readiness and effectiveness of military medical teams. Future research should focus on developing a centralized training curriculum that aligns with the evolving demands of modern military operations and tests its efficacy in improving prehospital and battlefield medical outcomes.

Sports medicine (SM) is a clinical subspecialty concerned with the diagnosis and treatment of injuries and illnesses sustained both in and out of the athletic arena. Historically, orthopedic surgeons provided the bulk of care for the athlete. Since the majority of issues with athletes are nonoperative musculoskeletal injuries, traumatic brain injuries, or general medical conditions, primary care providers have developed an important role in SM. The primary care sports medicine (PCSM) physician has become increasingly popular with amateur and professional teams, as growth of sports participation has created medical demands that far exceed the ability of a single medical specialty to provide care.1 Orthopedic surgery practices have also realized the benefits of utilizing PCSM physicians to assist in patient care. The PCSM fellowship started in 1992 when the American Board of Emergency Medicine, the American Board of Pediatrics, the American Board of Family Practice, and the American Board of Internal Medicine made an application to the American Board of Medical Specialties (ABMS) to offer subspecialty certification in SM and received approval. Family medicine (FM) is the administering board and has offered written exams since 1993. Today, SM is 1 of only 6 fellowships recognized by the ABMS for emergency medicine (EM) physicians. SM should be appealing to emergency physicians, as patients with acute athletic injuries present to the emergency department on a fairly routine basis. Although there is no reliable sports injury tracking system, recent reports estimate over 4 million emergency department visits occur annually for injuries related to participation in sports and recreation.2 One could imagine that the demand for sports medicine fellowships would be high. The reality is that there is minimal participation in SM among EM clinicians, and in general there is very little participation in PCSM among any specialty other than FM. The sparse participation is not due to a lack of training opportunities. The majority (62%) of the 97 PCSM fellowship programs allow EM residents to apply. However, only 6 (6.2%) of these fellowships are run by EM, while 83 (85%) are run by FM departments. Currently, 0.5% (n = 101) of all board-certified EM attending physicians and 2.3% (n = 1,486) of all board-certified FM attending physicians are PCSM board certified.3 In our recent survey of 2008 to 2009 EM residency program directors with 89% (116/130) response rate, we found that 51% of program directors reported no SM practitioners.3 Seven percent of departments have 4 or more fellowship-trained attending physicians, while 66% of programs have no one who is fellowship-trained working in their department. In comparison, a mean 1.7 (95% confidence interval: 0.2–3.2) residents per program surveyed were reported to be interested in a career in SM. However, during the last 10 years, 60 EM residents in total have completed a PCSM fellowship following EM residency training. This number is surprisingly small and is inconsistent with the reported interest. There is no readily apparent answer as to why EM residents fail to pursue SM fellowships. Given the lack of prior penetration by EM physicians into SM, current residents with potential interest in SM have EM mentors to look to for guidance, teaching, and exposure to the field. While there are many SM fellowship positions available to EM residents, most of these fellowships are run by FM departments and, thus, may not appeal as much to EM applicants. In order to make a significant presence in SM, we must continue to encourage our residents to do SM electives, be involved in sports coverage, and apply to fellowships. For these opportunities to present themselves, programs must continue to hire fellowship graduates in order to mentor residents and train fellows of their own. If more EM based SM fellowships become available, there will be more EM mentors in the field and more EM resident exposure to SM. This would, in turn, likely lead to more resident participation in fellowship training. A letter to the editor in Academic Emergency Medicine in 20034 discussed the EM ultrasound fellowship and said that these fellowships are needed to advance the field and to provide EM physicians the expertise in ultrasound. Similarly, SM fellowship training is also needed in the field of EM to advance research and to develop EM leaders within the subspecialty. Without this type of growth, SM will continue to be dominated by FM, and EM will never gain a presence in a subspecialty that seems to best suit the EM physician.

The purpose of the study was to assess the knowledge of dietary supplements (DS) and adverse event (AE) reporting practices of the Department of Defense health care providers. AEs related to use of DS are not uncommon. However, it is estimated that less than 2% of AEs are reported. This is problematic given the Food and Drug Administration relies on AE reports to identify and ultimately remove unsafe products from the market. Inadequate reporting of AE puts all DS users at risk. Cross-sectional design was used. Electronic surveys were sent to the Department of Defense health care professionals (HCPs) and Emergency Medicine (EM) physicians asking questions about practices regarding DS and AE knowledge and reporting behaviors. The surveys were open for 5months. During this period of time, HCPs received three email reminders following the initial email to enhance participation. The computer package IBM SPSS version 25 software (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 21.0, Armonk, New York) was used for statistical analysis. Frequency distributions of the responses were analyzed. Of the 1,700 surveyed, 270 HCPs and 68 EM physicians completed the surveys. At least 39% of HCPs reported never receiving formal DS training. Seventy-two percent of HCPs reported asking their patients about the use of DS. However, when asked if they knew where to report an AE, only 40% of HCPs knew where to report an AE and only 38% knew how to report an AE. Of the EM physicians, only 38% asked their patients about DS. However, a majority (78%) reported that they had encountered an AE. EM physicians also reported they lacked knowledge regarding where (87%) and how (87%) to report AE. It is clear that physician and nonphysician HCPs would benefit from additional training about DS and how and where to report suspected AE. Providing regular training on risks, common AE, and how and where to report an AE would help fill the knowledge gap in the ever-changing DS industry. Addressing these issues and coming up with a solution to integrating AE reporting into clinical care could improve health care practices and increase AE reporting to the Food and Drug Administration, which would have a beneficial impact on patient care, public safety, and mission readiness.

Use of social media (SM) by physicians has exposed issues of privacy and professionalism. While guidelines have been created for SM use, details regarding specific SM behaviors that could lead to disciplinary action presently do not exist. To compare State Medical Board (SMB) directors' perceptions of investigation for specific SM behaviors with those of emergency medicine (EM) physicians. A multicenter anonymous survey was administered to physicians at 3 academic EM residency programs. Surveys consisted of case vignettes, asking, "If the SMB were informed of the content, how likely would they be to initiate an investigation, possibly leading to disciplinary action?" (1, very unlikely, to 4, very likely). Results were compared to published probabilities using exact binomial testing. Of 205 eligible physicians, 119 (58%) completed the survey. Compared to SMB directors, EM physicians indicated similar probabilities of investigation for themes involving identifying patient images, inappropriate communication, and discriminatory speech. Participants indicated lower probabilities of investigation for themes including derogatory speech (32%, 95% confidence interval [CI] 24-41 versus 46%, P < .05); alcohol intoxication (41%, 95% CI 32-51 versus 73%, P < .05); and holding alcohol without intoxication (7%, 95% CI 3-13 versus 40%, P < .05). There were no significant associations with position, hospital site, years since medical school, or prior SM professionalism training. Physicians reported a lower likelihood of investigation for themes that intersect with social identity, compared to SMB directors, particularly for images of alcohol and derogatory speech.