EM Faculty Research Articles

Diabetes mellitus treatment—Related medical knowledge among health care providers

ObjectiveTo compare the knowledge of physicians, residents and medical students in diagnosis, use of insulin and oral medication in management of Type 2 Diabetes Mellitus (DM) working in different healthcare specialties. MethodsA cross sectional survey of faculty, residents and medical students of different subspecialties in a single center was conducted. Questionnaire consisting of 20 questions was used. These questions were designed to assess knowledge about diagnosis, nomenclature of different insulin/oral medications and management of DM. There were 4 answers to every question with only one correct answer based on ADA guidelines and most recent literature. ResultsThe overall percentage correctly answered questions was ∼74% for IM faculty, 64% for EM faculty, 71% for IM residents, 60% for FM residents, 56% for EM residents and 59% for students. Questions based on knowledge of insulin nomenclature and characteristics were answered correctly 74% of the time by IM faculty, 62% by EM faculty, 66% by IM residents, 69% by FM residents, 45% by EM residents and 49% by medical students. Questions on the use of insulin and inpatient DM management were answered correctly 66% for IM faculty, 54% for EM faculty, 66% for IM residents, 46% for FM residents, 55% for EM Residents, and 44% medical students. Questions based on oral medications and DM diagnosis were answered correctly by 81% for IM faculty, 73% for EM faculty, 78% for IM Resident, 76% FM Resident, 64% for EM residents and 79% for students. ConclusionThis study demonstrates the need for focused educational initiatives required in all subspecialties involved in management of diabetes mellitus for safe and efficient management of diabetes mellitus.

Reporter-Interpreter-Manager-Educator (RIME) Descriptive Ratings as an Evaluation Tool in an Emergency Medicine Clerkship

BackgroundEmergency Medicine (EM) clerkships traditionally assess students using numerical ratings of clinical performance. The descriptive ratings of the Reporter, Interpreter, Manager, and Educator (RIME) method have been shown to be valuable in other specialties. ObjectivesWe hypothesized that the RIME descriptive ratings would correlate with clinical performance and examination scores in an EM clerkship, indicating that the RIME ratings are a valid measure of performance. MethodsThis was a prospective cohort study of an evaluation instrument for 4th-year medical students completing an EM rotation. This study received exempt Institutional Review Board status. EM faculty and residents completed shift evaluation forms including both numerical and RIME ratings. Students completed a final examination. Mean scores for RIME and clinical evaluations were calculated. Linear regression models were used to determine whether RIME ratings predicted clinical evaluation scores or final examination scores. ResultsFour hundred thirty-nine students who completed the EM clerkship were enrolled in the study. After excluding items with missing data, there were 2086 evaluation forms (based on 289 students) available for analysis. There was a clear positive relationship between RIME category and clinical evaluation score (r2=0.40, p<0.01). RIME ratings correlated most strongly with patient management skills and least strongly with humanistic qualities. A very weak correlation was seen with RIME and final examination. ConclusionWe found a positive association between RIME and clinical evaluation scores, suggesting that RIME is a valid clinical evaluation instrument. RIME descriptive ratings can be incorporated into EM evaluation instruments and provides useful data related to patient management skills.

Emergency Medicine in the Medical School Curriculum

AbstractEmergency medicine (EM) is a dynamic specialty that continues to define itself as a fertile training ground for medical students. Throughout the years, a number of U.S. medical schools have incorporated topics germane to EM training (basic cardiac life support, principles of wound care, splinting, basic procedural skills training, etc.) into the medical school curriculum. By virtue of their broad‐based training and the unique patient care environment that they practice in, EM specialists can serve a multitude of educational roles in the medical school. Whether serving as a problem‐based learning facilitator, collaborating with basic scientists, or teaching medical history‐taking and physical examination skills in the emergency department (ED), EM faculty can effectively teach future physicians in training. Although opportunities for teaching will vary by institution, often all it takes to get involved is asking. Teaching can take place in the ED, classroom, or simulation center, both in the preclinical and in the clinical curriculum. EM faculty may be well suited to help teach procedural skills to students as they enter their clinical clerkships. A formal rotation in EM can also assist the medical school in achieving their institutional objectives or in identifying ways to satisfy the Liaison Committee on Medical Education’s objectives. Patients presenting to the ED span the entire spectrum: young and old, sick and not sick. It is this variety of cases that makes the ED a truly valuable setting for educating students.ACADEMIC EMERGENCY MEDICINE 2010; 17:S26–S30 © 2010 by the Society for Academic Emergency Medicine

286: Clinical Teaching In a Busy Emergency Department: Interruptions During Case Presentations

In the emergency department (ED) of a teaching hospital, attending physicians are challenged to instruct medical students and residents while simultaneously caring for critically ill patients. Thus, they must balance the need to quickly devise patient assessments and plans with their responsibility to devote time toward teaching students. Studies have only recently begun to quantify and characterize interruptions occurring in the ED. Our objectives were to determine the frequency and nature of interruptions by the training physician that occur when medical trainees perform oral case presentations (OCPs). This was a prospective observational study which took place from June 2009 through August 2009 in the ED of a large academic medical center. A convenience sample of house officers and fourth-year medical students were observed during OCPs with attending physicians. None of these physicians or students were aware of the purpose of the study. They were informed only that a second-year medical student was observing case presentations as part of his/her summer elective. As many different attending physicians as possible were sampled while maintaining equal hours of observation for each daily shift. The student completed a simple data sheet after each case presentation and recorded OCP duration, interruption frequencies, and interruption types. An “interruption” was defined as any event that caused the learner to stop the OCP for longer than 2 seconds, and only interruptions initiated by the teaching physician were recorded. Effects of learner level or time of day on frequency of interruption were evaluated using analysis of variance, with statistical significance at the p < 0.05 level. A total of 570 case presentations were observed during the study period; involving 53 EM faculty, 52 house staff and 11 medical students. The mean duration of presentation was 3.4 + 2.2 minutes (range 0.5 to 14 minutes). There were a total of 1739 interruptions during case presentations; mean 3.0 (+ 2.4) interruptions per presentation or 0.94 (+ 0.70) interruptions per minute. At least one interruption occurred in 94% of OCPs, with a maximum of 16. The interruptions were categorized as follows: interruptions by faculty (88%), phone calls (4%), questions by nursing staff (7%), ECG interpretation (1%), and orders on other patients (1%). The majority of faculty interruptions (55%) involved questions about history or exam findings or injection of teaching points. In 37% of OCPs, attending physicians interrupted to give an assessment and/or a treatment plan before the learner had done so. The number of interruptions (per OCP) and duration of OCP varied by learner level of training (p < 0.01), with more experienced learners giving shorter presentations and being interrupted less often. Neither frequency nor number (per OCP) of interruptions was statistically different by time of day. The education of students and residents occurs primarily during case presentations to ED faculty, an environment in which interruptions frequently occur. The majority of these interruptions are driven by the faculty themselves and vary by the learner level of training. These interruptions can be potentially beneficial, such as the injection of timely teaching points or clarification of clinical findings.

Academic Emergency Medicine Faculty and Industry Relationships

The authors surveyed the membership of the Society for Academic Emergency Medicine (SAEM) about their associations with industry and predictors of those associations. A national Web-based survey inviting faculty from the active member list of SAEM was conducted. Follow-up requests for participation were sent weekly for 3 weeks. Information was collected on respondents' personal and practice characteristics, industry interactions, and personal opinions regarding these interactions. Raw response rates were reported and a logistic regression was used to generate descriptive statistics. Responses were received from 430 members, representing 14% of the 3,183 active members. Respondents were 83% male and 86% white, with 96% holding an MD degree (24% with an additional postdoctoral degree). Most were at the assistant (37%) or associate (25%) professor rank, with 51% holding at least one leadership position. Most respondents (82%) reported some type of industry interaction, most commonly the acceptance of food or beverages (67%). Respondents at the associate professor rank or higher were more likely to receive payments from industry (51% vs. 22%, odds ratio [OR] = 3.7). This survey suggests that interactions between industry and academic EM faculty are common and increase with academic rank, but not with years in practice or leadership influence. The number and type of interactions are consistent with those reported by a national sampling of other physician specialties.

Securing an Airway When You Can’t Reach the Patient

Prehospital personnel (including physicians who participate in disaster relief or emergency medical services operations) might encounter patients who require airway management while they are trapped in vehicles, under debris, or in other confined spaces. In a prospective study, 22 paramedics, 25 emergency medicine residents, and 9 EM faculty attempted to intubate manikins in three different scenarios: manikin lying supine under a table with …

Academic emergency medicine staffing nonacademic emergency department sites: a national survey.

Changing health care markets have threatened academic health centers and their traditional focus on teaching and research. To determine the number of academic emergency medicine departments (AEMDs) that staff additional non-academic ED sites and to determine whether clinical reimbursement monies from those ED sites are used for academic purposes. A two-part survey of all 119 academic EM programs listed in the 1997-1998 Graduate Medical Education Directory was conducted. Questionnaires were addressed to each AEMD chair. AEMDs and ED sites were characterized. Hiring difficulties, EM faculty academic productivity, and use of ED site reimbursement monies for academic activities were assessed. Ninety-nine of 119 (83%) AEMDs responded. Twenty-three (23%) AEMDs staffed 28 added ED sites. These sites tended to be urban (65%), with moderate volumes (25,000-35,000 patients/year), and had an equal or better reimbursement rate than the AEMD (89%). ED sites were commonly staffed by academic EM faculty (79%) and EM residents (29%). Ninety-six percent of the AEMDs had hired additional faculty; hiring new faculty was considered easy. Academic productivity at AEMDs with added ED sites was reported as unchanged. Reimbursement monies from these ED sites were commonly used for faculty salary support, faculty development, and EM research and residency activities. Academic EM departments are often affiliated with nonacademic ED sites. These additional sites are commonly staffed by academic EM faculty and EM residents. Academic productivity does not appear to decrease when additional ED sites are added. Reimbursement monies from these ED sites commonly supports academic activities.

Academic departments of emergency medicine: the effects of managed care.

To survey academic departments of emergency medicine (ADEMs) concerning the effects of managed care on their operation and practice. A 38-question survey was mailed to the chairs of all 52 ADEMs in the United States requesting information concerning managed care activity and its effects on ADEMs in academic years 1994-1995 and 1995-1996. Forty-seven ADEMs (90.3%) responded. When comparing the 1995-1996 and 1994-1995 academic years, the following changes were noted: decreased overall growth in ED patient volume (38.3% vs 51.1%), larger percentage of respondents reporting an actual decrease in ED patient volume (38% vs 27.6%), less growth in ED gross revenue (43.7% vs 52.1%), larger percentage of ADEMs reporting actual decreased gross revenues (25% vs 12.5%), increase in ED patient acuity (76.6% vs 59.6%), and relative stability in the number of EM faculty (40.4% vs 44.7% reporting no change in faculty number). Two-thirds of ADEMs used mid-level providers (i.e., physician assistants, nurse practitioners), most commonly in a fast-track setting (41%). Thirty percent of ADEMs reported that other academic departments actively directed patients away from the ED, with pediatrics, family medicine, and internal medicine the most active. Ninety-eight percent of ADEMs reported ongoing negotiations between their institution or hospital and managed care organizations (MCOs); only 54.3% of ADEMs were involved in these negotiations. Twenty-eight percent of ADEMs reported MCOs have had an effect on their emergency medical services system, with 37% indicating HMOs routinely discouraged their enrollees from using 9-1-1 services and 16% reporting HMOs provided 9-1-1 services to take patients only to participating hospital EDs. ADEMs have experienced significant changes in nearly every aspect of their practice over the two academic years under study, much of which is due to managed care. ADEMs must take a leadership role in dealing with MCOs.

Tenure Track in Emergency Medicine

Study objective: Tenure was designed to guarantee academic freedom through lifelong job security. Productive research, especially in the basic sciences, is the main criterion for tenure at most institutions; therefore faculty in more clinically focused specialties may experience more difficulty obtaining tenure. We examined the relationship between academic emergency medicine and tenure. Methods: We used a questionnaire to survey the directors of all 108 approved US emergency medicine residency programs. The surveyed population was asked whether the program was affiliated with a medical school, the number of full-time faculty, and how many faculty members were tenured or on the tenure track. Follow-up mailings were sent to nonresponders. We also conducted a search of the Association of American Medical Colleges (AAMC) database to compare the number of emergency medicine faculty involved in the tenure process in other specialties. Results: One hundred surveys (93%) were returned. At programs in which faculty were eligible for tenure, 9% (95% confidence interval [CI], 4% to 16%) were tenured and 27% (95% CI, 19% to 37%) were on the tenure track. Therefore only 36% of all EM faculty (95% CI, 27% to 46%) were tenured or on the tenure track. Among the 53 residency programs that offered tenure, 45% (95% CI, 32% to 60%) had no tenured faculty. At programs with academic department status, 74% of chairs were tenured, in contrast to only 32% of chiefs at institutions without academic department status (95% CI for difference of 42%, 14% to 71%). The AAMC survey revealed that about one-third as many emergency medicine faculty members were tenured compared with the other specialties. The proportion of faculty on the tenure track, however, was similar between the specialties. Conclusion: Most eligible emergency medicine faculty members are not tenured or on track to become tenured, and fewer emergency medicine faculty are tenured compared with the more traditional specialties. Emergency medicine may be vulnerable to being considered less academic unless its faculty members gain access to the tenure process. [Wright SW, Slovis CM: Tenure track in emergency medicine. Ann Emerg Med November 1997;30:622-625.]

Reliability of faculty clinical evaluations of non-emergency medicine residents during emergency department rotations.

To assess the reliability of faculty evaluations of non-emergency medicine (non-EM) residents during clinical ED rotations and to determine the effect that the "leniency" of grading by these evaluators had on the residents' final evaluations. A prospective, observational study of the evaluation patterns of EM faculty was performed in an academic ED (50,000 visits yearly census). Each resident was evaluated on a daily basis by a board-certified or board-prepared emergency physician. The evaluation form rated 7 characteristics, but only the rating for overall clinical competence was used for data analysis. If an attending evaluated the same resident more than once, only the first evaluation was used to avoid bias from prior exposure. The scoring patterns of the evaluators, both individually and in groups, were analyzed using 1-way analysis of variance. Evaluator leniency was estimated using the mean evaluator score across all residents. Since each resident was evaluated by a different combination of evaluators, evaluator leniency for each resident was estimated from the mean leniency of the evaluators who specifically assessed that resident. During the period of the study, 66 residents rotated through the ED, yielding a total of 401 evaluations. When the scoring patterns of individual evaluators were analyzed, a high degree of variability was found in the mean scores (range 5.23-8.09) and SDs (range 0.45-1.55) across evaluators; p = 0.0001. There was a moderate correlation between the mean overall competence score received by each resident and that resident's evaluators' leniency, r = 0.52; p = 0.0001. There is significant variability in the scoring patterns of individual evaluators. The evaluators in this study showed large variations in both leniency (as measured by their mean score) and range restriction (as measured by their SD). The differences in evaluator scoring leniency have a moderate correlation with the overall score received by the resident.

Rate of Patient Workups by Non–Emergency Medicine Residents in an Academic Emergency Department

To quantify the number of patients seen per hour by non-emergency medicine (non-EM) residents in a university hospital ED. This retrospective observational study was performed in a university hospital ED and level I trauma center. The facility had no EM residency, but was staffed with 24-hour EM faculty coverage. A computerized tracking system was searched for the number of patients seen by each of 93 non-EM residents for 12 nonconsecutive months. The ED schedule for each month was used to calculate the number of hours worked by each resident. From these figures, the number of patients seen per hour by each resident was calculated. The postgraduate years of training of the residents were as follows: 78 (84%) were PGY1, ten (11%) were PGY2, and five (5%) were PGY3. All the residents combined saw a mean 0.95 +/- 0.20 patients/hour, with a range from 0.58 to 1.75 patients/hour. There was no significant difference between the numbers of patients seen when compared by specialty using the Tukey-Kramer test (alpha = 0.05). The rate at which non-EM residents work up patients is consistent with previously reported rates for EM residents.