Emergency Medicine Clerkship Research Articles

Emergency Medicine Clerkship Grading Scheme, Grade, and Rank-List Distribution as Reported on Standardized Letters of Evaluation

Background: The Standardized Letter of Evaluation (SLOE) is a crucial component of the emergency medicine (EM) application process. Given the critical role of the SLOE, we attempted to better understand the grading scales used, as well as the distribution of grades and rank-list positions.Objectives: Our primary objective in this study was to determine the distribution of grading formats, grades given, and rank-list positions across EM clerkships using the SLOE. Methods: We performed a cross-sectional study of the grading formats, grades given, and ranking distributions as reported on the SLOE during the 2022–23 application cycle. We obtained data on SLOEs from EM residency programs accredited by the Accreditation Council for Graduate Medical Education by reviewing all applicants who applied to either of two EM residency programs in geographically different regions. Trained abstractors recorded the following data: number of students rotating in the prior year; grading format used; and grade and rank distribution among students. Results: We included 264 programs in our final analysis, after 13 programs met exclusion criteria. The majority of programs (72.2%) use an Honors/High Pass/Pass/Fail grading scheme. We determined the mean percent of each grade: Honors/A 27.6%; High Pass/B 31.1%; Pass/C 40.8%; Low Pass/D 0.2%; and Fail/F 0.3%. Finally, we determined the mean percent for each rank-list position: top 10% was 17.6%; top third 36.5%; mid third 34.1%; and low third 11.8%. Conclusion: We determined the grading schemes and grade and rank-list distributions for EM programs during the 2022–2023 academic year. Most programs used a Honors/High Pass/Pass/Fail grading scheme, with the majority of students receiving Honors or High Pass, while 0.3% failed their rotation. Both grades and rank list demonstrated evidence of a skewed distribution toward higher grades and rank-list position.

Resident Instruction: Improving End-of-Year Medical Student Ultrasound Performance.

Having a limited number of trained faculty is a barrier to successful incorporation of ultrasound into undergraduate medical education. We evaluated the effectiveness of a resident-led extended focused assessment with sonography in trauma (eFAST) session administered to fourth-year medical students during their emergency medicine clerkship by measuring students' end-of-year eFAST performance and confidence. This was a single-site cross-sectional study of all graduating medical students enrolled in fourth-year clerkships between May 1, 2022 and April 30, 2023. A 60-minute, team-based eFAST session (intervention), taught by emergency medicine residents, was added to students' fourth-year emergency medicine clerkship in September 2022. All students were assigned to review an eFAST video (control). End-of-year performance and self-reported confidence assessments used a 20-point objective structured clinical examination (OSCE) and a 5-point Likert scale, respectively. The mean OSCE and confidence scores for control and intervention groups were compared using two-sample t tests and repeated after removing students exposed to additional US experiences. Of 113 eligible students, 103 students participated: 48 in the control group, 55 in the intervention group. The intervention group scored higher on the OSCE than the control group (11.9 ±4.6 vs 9.9 ±5.1, P=.04) and reported similar confidence (3.2 ±1.0 vs 2.8 ±1.2; P=.09). After removing the 28 students with additional US experiences, the intervention group scored higher (10.8 ± 4.4 vs 8.2 ± 4.0; P=.01) and reported higher confidence (3.0 ±1.0 vs. 2.3 ±1.0, P=.01). Resident-taught eFAST instruction during emergency medicine clerkships led to improved end-of-year fourth-year medical student eFAST performance and confidence.

Medical Students' Competency in EFAST (Extended Focused Assessment Sonography for Trauma) Components: A Prospective Observational Study.

Ultrasound training in undergraduate medical education is developing, and its incorporation into the curriculum requires careful planning. Extended Focused Assessment Sonography for Trauma (EFAST) is commonly taught to medical students as one of the primary applications of ultrasound. Because false-negative EFAST scans can affect patients' clinical outcomes, it is essential to evaluate the individual components of this skill. We aim to determine which EFAST components students perform sub-optimally after initial training. In this prospective observational study, 90 medical students from two final-year cohorts were assessed in EFAST components after uniform training during the emergency medicine clerkship. All validated components of the standard EFAST exam were assessed, and a descriptive analysis of individual components of EFAST was performed. The hepatorenal space, splenorenal space, and pelvic space fluid investigations had the lowest completion rates. Pericardial fluid, pelvic free fluid, and right thoracic pleural fluid investigations were often incorrectly applied. Fanning was most commonly missed in hepatorenal, splenorenal, and pelvic free fluid investigations, and between 12% and 50% of EFAST components had omitted reporting. There were significant incomplete assessments for free intraperitoneal fluid, primarily due to a lack of fanning in the hepatorenal, splenorenal, and pelvic areas. Trainers can effectively enhance student performance and outcomes by targeting these challenging areas. Further research might reveal whether residents and physicians show similar trends in EFAST completion.

Snapshot of Examination Usage in Emergency Medicine Clerkships.

Objective Emergency Medicine (EM) clerkships often use a written exam to assess the knowledge gained over the course of an EM rotation in medical school. Clerkship Directors (CDs) may choose the National Board of Medical Examiners (NBME) EM Advanced Clinical Science Subject Exam (ACE), the Society for Academic Emergency Medicine (SAEM) M4 exam, which has two versions, the SAEM M3 exam, or departmental exams. There are currently no published guidelines or consensus regarding their utility. This survey-based study was designed to collect data regarding current practices of EM clerkship exam usage to analyze trends and variability in what exams are used and how. Methods The authors designed a cross-sectional observational survey to collect data from EM CDs on exam utilization in clerkships. The survey population consisted of clerkship directors, assistant clerkship directors, or faculty familiar assessments in their EM clerkship. Initial dissemination was by electronic distribution to subscribers of the Clerkship Directors in Emergency Medicine (CDEM) list-serve on the SAEM website. Subsequently, contact information of CD's from institutions that had not responded was obtained by manual search of the Emergency Medicine Residents' Association (EMRA) Match website and individual correspondence was sent at regular intervals. Data obtained include clerkship characteristics, exam used, weight of the exam relative to the overall grade, and alternatives if the preferred exam was previously taken. Results Eighty-seven programs (42% response rate) completed the survey between August 2019 and February 2021. Of the 87 responses, 71 (82%) were completed by a CD. Forty-six (53%) institutions required an EM rotation. Students were tested in 34 (74%) required EM clerkships and 48 (69%) out of 70 EM electives. In required rotations that used an exam, 20 (59%) used the NBME EM ACE, while 28 of 46 (61%) of EM electives that reported an exam used the SAEM M4 Exam. Five (15%) of the required clerkships used a departmental exam. Of clerkships requiring an exam, 46 (57%) weighed the score at 11-30% of the final grade. Data for extramural rotations mirrored that of EM electives. One-third of respondents indicated they do not inquire about previously taken exams. Conclusion This survey demonstrates significant variability in the type of exam, the weighting of the score, and alternatives if the preferred exam was previously taken. The lack of a consistent approach in how these exams are used in determining students' final EM grades diminishes the reliability of the EM clerkship grade as a factor used by residency directors in choosing future residents. Further research on optimal usage of these exams is needed.

Evaluation of high-fidelity and virtual reality simulation platforms for assessing fourth-year medical students’ encounters with patients in need of urgent or emergent care

Background Medical students in the U.S. must demonstrate urgent and emergent care competence before graduation. Urgent and emergent care competence involves recognizing, evaluating and initiating management of an unstable patient. High-fidelity (HF) simulation can improve urgent and emergent care skills, but because it is resource intense, alternative methods are needed. Study Objective Our primary purpose was to use program evaluations to compare medical student experiences with HF and virtual reality (VR) simulations as assessment platforms for urgent and emergent care skills. Methods During their emergency medicine clerkship, students at The Ohio State University College of Medicine must demonstrate on HF manikins, competence in recognizing and initiating care of a patient requiring urgent or emergent care. Students evaluated these simulations on a five-point quality scale and answered open-ended questions about simulation strengths and weaknesses. Faculty provided feedback on student competence in delivering urgent or emergent care. In 2022, we introduced VR as an alternative assessment platform. We used Wilcoxon Signed Ranks and Boxplots to compare ratings of HF to VR and McNemar Test to compare competence ratings. Comments were analyzed with summative content analysis or thematic coding. Results We received at least one evaluation survey from 160 of 216 (74.1%) emergency medicine clerkship students. We were able to match 125 of 216 (57.9%) evaluation surveys for students who completed both. Average ratings of HF simulations were 4.6 of 5, while ratings of VR simulations were slightly lower at 4.4. Comments suggested that feedback from both simulation platforms was valued. Students described VR as novel, immersive, and good preparation for clinical practice. Constructive criticism identified the need for additional practice in the VR environment. Student performance between platforms was significantly different with 91.7% of students achieving competence in HF, but only 65.5% in VR (p≤.001, odds-ratio = 5.75). Conclusion VR simulation functions similarly to HF for formative assessment of urgent and emergent care competence. However, using VR simulation for summative assessment of urgent and emergent care competence must be considered with caution because students require considerable practice and acclimation to the virtual environment.

Innovations report: A grading committee for a required fourth-year emergency medicine clerkship.

Assessment of medical students in the clinical learning environment is fraught with challenges. Seemingly small variations in clinical clerkship evaluation can significantly impact a student's future. As such, the integrity of the grade selection process must be heavily scrutinized. Group decision making in the form of a clerkship grading committee may be part of a solution to address this complex problem. We conducted a retrospective observational study to describe grading committee decisions for a required fourth-year EM clerkship from August 2021 to April 2022. Literature on best practices for group decision making and assessment were reviewed. This informed the development and implementation of the committee process. Each committee meeting was video recorded and coded for discussion time per student, times the committee grade differed from historical-grade cutoffs with reasoning, and the frequency a committee member voiced a first-hand account of student performance. Data from nine meetings was reviewed (86 students). The mean discussion time per student was 2 min 13 s (range 11 s to 9 min 22 s). The final committee decision differed from historical-grade cutoffs for nine students (10%), six were adjusted above and three below. In 64% (55/86) of student reviews a committee member voiced a first-hand experience of working with the student. Positive grade adjustments were made due to outlier evaluations and negative adjustments were made for professionalism concerns. Grading committees are a means to conduct a comprehensive review of student performance and offer shared ownership of the grade decision among committee members. More study is needed to directly determine their potential benefit and role in clerkship grading.

Exploring Medical Student Experiences of Trauma in the Emergency Department: Opportunities for Trauma-informed Medical Education.

During the third-year emergency medicine (EM) clerkship, medical students are immersed in traumatic incidents with their patients and clinical teams. Trauma-informed medical education (TIME) applies trauma-informed care (TIC) principles to help students manage trauma. We aimed to qualitatively describe the extent to which students perceived the six TIME domains as they navigated critical incidents during their EM clerkship. We employed a constructivist, modified grounded theory approach to explore medical students' experiences. We used the critical incident technique to elicit narratives to better understand the six TIME domains as they naturally appear in the clerkship. Participants were asked to describe a traumatic incident they experienced during the clerkship, followed by the clerkship's role in helping them manage the incident. Using the framework method, transcripts were analyzed 1) deductively by matching transcript excerpts to relevant TIME domains and 2) inductively by generating de novo themes to capture factors that affected students' handling of trauma during critical incidents. Twelve participants were enrolled and interviewed in July 2022. "Safety" was the most frequently described TIME domain, whereas "Gender, Cultural, and Historical issues" and "Peer Support" were discussed least. Inductive analysis revealed themes that hindered or supported their ability to manage traumatic experiences, which were grouped into three categories: 1) student interactions with the learning environment: complex social determinants of health, inequalities in care, and overt discrimination; 2) student interactions with patients: ethically ambiguous care, witnessing acute patient presentations, and reactivation of past trauma; and 3) student interactions with supervisors: power dynamics, invalidation of contributions, role-modeling, and student empowerment. The six TIME domains are represented in students' perceptions of immediate, stressful critical incidents during their EM clerkship, with "Safety" being the most commonly described; however, the degree to which these domains are supported in students' experiences of the EM clerkship differ, and instances of inadequately experienced domains may contribute to student distress. Understanding the EM clerkship through the specific lens of students' experiences of trauma may be an effective strategy to guide curricular changes that promote a supportive learning environment for students in the emergency department.

Community-engaged pedagogy in an emergency medicine clerkship: Teaching trauma-informed addiction care and harm reduction through a peer-assisted learning case.

The impact of opioid use disorder (OUD) in the United States continues to rise, yet this topic has limited coverage in most medical school curricula. The study partnered with academic and community harm reductionists to design a peer-assisted learning case of opioid withdrawal to teach fourth-year medical students about trauma-informed OUD care and harm reduction services during their emergency medicine clerkship. Academic and community harm reductionists iteratively codesigned this case in partnership with the research team. Community-engaged pedagogy informed this process to promote social action and power sharing through education. This case was integrated into the existing weekly peer-assisted learning curriculum (i.e., medical students teaching medical students through a structured case) for all fourth-year medical students during their required emergency medicine clinical rotation. Participants completed a postcase evaluation survey. Sixty-four medical students completed the survey between June and November 2022. A total of 98.5% of participants found the educational session quite or extremely relevant to their medical education, and 87.5% believed the case to be quite or extremely effective in achieving the learning objectives. A total of 45.3% initially felt quite or extremely competent in talking with patients about their drug use, whereas 53.2% felt quite or extremely more competent after participating in the case. Finally, 21.9% initially felt quite or extremely competent in proposing a treatment plan for a patient who uses drugs, whereas 62.5% felt quite or extremely more competent after participating in the case. This study supports the feasibility and importance of incorporating the voices of people with lived and living experience into medical school curricular development. This peer-assisted learning case focused on the treatment of OUD in the emergency department was seamlessly integrated into the existing curriculum and well received by medical students. By engaging local experts, it could easily be adapted and expanded to other sites.

Effectiveness of near-peer instruction during emergency medicine clerkships on fourth-year student end-of-year eFAST performance

Effectiveness of near-peer instruction during emergency medicine clerkships on fourth-year student end-of-year eFAST performance

Beyond the Flashing Lights: Incorporating EMS Education Into an Emergency Medicine Clerkship Curriculum

Beyond the Flashing Lights: Incorporating EMS Education Into an Emergency Medicine Clerkship Curriculum

FoEM Clerkship: An Open-Access Case-Based Flipped Classroom Curriculum for Emergency Medicine Clerkships

FoEM Clerkship: An Open-Access Case-Based Flipped Classroom Curriculum for Emergency Medicine Clerkships

Demographics, Training, and Longevity of Emergency Medicine Clerkship Directors: a National Survey

Demographics, Training, and Longevity of Emergency Medicine Clerkship Directors: a National Survey

Development and evaluation of a novel knowledge assessment tool for pediatric emergency medicine clerkships.

This study seeks to determine validity evidence for a newly developed multiple-choice examination (MCE) tool to assess retention and application of medical knowledge of students enrolled in a pediatric emergency medicine (PEM) clerkship. A team of PEM physicians created a 110-item MCE covering the range of clinical topics in PEM relevant for medical students. The researchers determined examination content using the report of Clerkship Directors in Emergency Medicine and PEM Interest Group of the Society for Academic Emergency Medicine (SAEM). The authors administered the MCE to fourth-year medical students at the end of their PEM rotation from May 2020 to April 2023 at four institutions and then analyzed the examination using four of Messick's five sources of validity evidence: content, response process, internal structure, and relation to other variables. A total of 158 students took the test. In academic year (AY)20-21, 47 students took the test and scored, on average, 81%. After revision of poor and indeterminate questions, the 111 medical students who took the revised version of the test in AY21-AY23 scored on average 77.3% with a standard deviation of 5.7% with a normal distribution in scores. The revised questions were rated as excellent (10.0%), good (26.4%), fair (34.5%), poor (24.5%), or indeterminate (4.5%) based on test item discrimination. There was a positive correlation between MCE scores and students' clinical evaluations but no correlation between MCE scores and scores that students received on their clinical notes or patient presentations during case conference. This novel PEM clerkship examination is a reliable test of medical knowledge. Future directions involve evaluating consequences of the MCE and offering the test to medical students in a dedicated PEM rotation at the national level.

Medical Students' Perceptions on Identifying and Addressing Emotional Responses in Emergency Medicine: Pilot Investigation.

Training in acute care, such as emergency medicine (EM), where exposure to critically ill and injured patients is high, impacts the well-being of trainees and contributes to burnout. Investigating how, and if, trainees prepare for these situations is necessary to ensure they are supported. This study aimed to evaluate medical students' perspectives and emotional preparedness for handling acute care and trauma. We conducted a pilot investigation using a remote digital survey of medical students during their EM clerkship at a large, urban academic institution. The primary outcome of interest was student-reported preparedness and comfort in handling trauma and critical care patient encounters. Secondary outcomes included awareness of well-being resources and comfort in accessing digital well-being resources. A total of 57 medical students completed the voluntary digital survey, and half of the students (n=28, 49%) reported having witnessed the care of a critically ill or a penetrating trauma patient (eg, a victim of gun violence). A majority (n=40, 70%) had thought about how these events may impact them, and over half felt unprepared to identify the emotional impact these cases may have on them (n=31, 54%) or address the emotional or mental health impact (n=36, 63%). Less than a quarter (n=14, 25%) were aware of digital mental health resources, and 58% (n=33) did not feel fully comfortable connecting with resources if needed. Students who had previously witnessed critical care were significantly more likely to report feeling well prepared in identifying the emotional impact and addressing this impact. In this cross-sectional survey, students did not feel fully prepared to identify or address the emotional impact of working in EM. Additionally, they lacked awareness of or comfort with accessing digital institutional resources meant to support their well-being, such as a large web-based platform. These findings can help inform and guide interventions by educational and academic leaders. The aim would be to create and promote environments that empower students with tools to identify their own emotions and connect to well-being resources.

An Appy That Needs Epi: An Atypical Presentation of Anaphylaxis.

An Appy That Needs Epi: An Atypical Presentation of Anaphylaxis.

A Teach-the-Teacher Module for Human Trafficking Bedside Instruction.

Human trafficking (HT) is a public health issue that adversely affects patients' well-being. Despite the prevalence of trafficked persons in health care settings, a lack of educational modules exists for use in clinical contexts. We developed a 50-minute train-the-trainer module on HT. After piloting the workshop for faculty, fellows, and residents (n = 19) at the Society for Academic Emergency Medicine (SAEM) national conference, we implemented it in medical students' curricula during their emergency medicine clerkship at the University of Iowa (n = 162). We evaluated the worskhop by (a) a retrospective pre-post survey of self-reported ability to (1) define HT, (2) recognize high-risk signs, (3) manage situations with trafficked persons, and (4) teach others about HT, and (b) a 3-month follow-up survey to assess longitudinal behavior change. In both contexts, results demonstrated improvement across all learning outcomes (pre-post differences of 1.5, 1.3, 1.9, and 1.7 on a 4-point Likert-type scale for each learning objective above, respectively, at the SAEM conference and 1.2, 1.0, 1.3, and 1.3 at the University of Iowa; p < .001 for all). In the 3-month follow-up, we observed statistically significant changes in self-reported consideration of and teaching about HT during clinical encounters among learners who had previously never done either (p < .001 and p = .006, respectively). This train-the-trainer module is a brief and effective clinical tool for bedside teaching about HT, especially among people who have never previously considered HT in a clinical context.

Needs Assessment of Non-core Content for Podcasts in Emergency Medicine.

Study objective The purpose of this study was to assess the use of podcasts among emergency medicine (EM) students, residents, and attending physicians for non-core content. Methods A survey was administered to medical students interested in emergency medicine, current residents of emergency medicine, and attending physicians to determine which podcasts, if any, they listen to and how often. The purpose of listening to these podcasts was also evaluated and determined it was to learn the non-core content of the specialty. The survey was administered online via multiple platforms including Google Forms (Google, Inc., Mountain View, CA), email, and Twitter (San Francisco, CA). The survey was also distributed via messaging application and word of mouth. Results There were 52 responses that were received on the survey. Of the respondents,73.1% (N = 38) stated that they do listen to medical podcasts. Of these listeners, 21.2% (N= 11) stated that they listen to them once a year, 15.4% (N= 8) once a month, 11.5% (N= 6) once every two weeks, 19.2% (N= 10) weekly, 11.5% (N= 6) 1-2 days per week, 5.8% (N= 3) 3-4 days per week, 5.8% (N= 3) 5-6 days per week, and 9.6% (N= 5) daily. Based on the 52 responses received, 30.8% (N= 16) stated that they listen to them as a supplement to other sources of foundational content, 25% (N= 13) for general interest, 28.8% (N= 15) for entertainment, 7.7% (N= 4) as a primary resource to learn foundational content in their specialty, and 7.7% (N= 4) other. Based on the data metrics, 51.9% (N= 27) stated that 1-5 of the medical podcasts they listen to discuss the practice of emergency medicine, 44.2% (N= 23) stated that none do, and 3.8% (N= 2) stated that more than 10 do. The list of emergency medicine podcasts being listened to are as follows: EMplify, EM:RAP, EM Over Easy, EM Clerkship, Core EM, EM Basic, EMA, EM Cases, Internet Book of Critical Care, Pharm So Hard, EMCRIT, EM Board Bombs, PEM Rules, and REBEL CAST. When asked how important medical podcasts are for learning within the specialty, 44.2% (N= 23) reported not important, 26.9% (N= 14) reported somewhat important, and 28.8% (N= 15) reported very important. When asked how important medical podcasts are for learning outside the specialty, 40% (N= 20) reported not important, 48% (N= 24) reported somewhat important, and 12% (N= 6) stated very important. When asked if their program includes medical education podcasts as part of their curriculum, 18.4% (N= 9) responded yes, while 81.6% (N= 40) responded no. When asked if they believe medical education podcasts should be included as part of their curriculum, 52% (N= 26) stated yes, while 48% (N= 24) stated no. Conclusion Based on the results of the survey, roughly three-quarters of the surveyees listen to medical podcasts. Of the respondents,38.5% (N = 20) stated that they listen to these podcasts as some form of supplement to learning content (7.7% (N = 4) primary and 30.8% (N = 16) supplementary), which explains the rising availability of the number of podcasts related to emergency medicine. Of the respondents stating that medical podcasts should be included in their curriculum, 52% (N = 26) signifies the importance of quality learning that these medical podcasts provide to their listeners.

Practical tips for teaching the undifferentiated medical student in the emergency department.

Emergency medicine clerkships have become more prevalent in the third year of medical school, a time when students are immersed in the core clinical training of their undergraduate medical education. There is little guidance for clinician educators, however, on how to effectively scaffold learning for third-year medical students when rotating in the emergency department (ED) during core clerkships. The authors sought to provide best practices in teaching to leverage the rich learning environment of the ED - regardless of their specialty selections. Based on an extensive review of the literature spanning on-shift teaching, feedback, clinical medicine, and bedside teaching, the following twelve tips are offered to guide the instruction of the undifferentiated third-year medical student in the ED.

Medical Student Learning Experience With Attending or Resident Preceptors in the Emergency Department.

Objectives The emergency department (ED) provides a unique learning environment for medical students. However, environment, patient, and preceptor factors limit standardized teaching. We explored the most effective educational interactions for fourth-year medical students during an emergency medicine (EM) clerkship designed to allow clinical interaction with both residents and faculty. Methods This is an exploratory, prospective, needs assessment study of objective cards and surveys submitted by medical students as part of their month-long fourth-year clinical rotation at a tertiary care academic ED. Students marked which topics or procedures they had reviewed, and who had precepted them. In an exit survey, students were asked to rate how often they received individualized teaching and whether their educational goals were met when working with residents and attendings. Qualitative and quantitative data were collected anonymously with institutional review board (IRB) exemption. Results Shift card data was collected from 69 of the rotating students. Attendings tended to precept visual diagnostics while residents tended to teach technical procedures. Forty-four students completed the exit survey. Results showed that students felt they received individualized teaching from both attendings and residents (7.9 and 8.0 respectively, p = 0.059). Students felt their goals were met more when reporting to the residents than the attendings but not significantly so (8.6 and 8.0, respectively, p = 0.088). Additional themes were that students wanted more individualized experiences with the attendings and requested more dedicated teaching shifts. Conclusions Fourth-year medical students in the ED felt they received individualized teaching on most shifts. They reported their education goals were met as often when working with residents as with attendings; however, interactions feature different educational content. Clerkship curricula design would benefit from resident and attending-directed teaching experiences to optimize the educational experience in the ED.

An Examination of Trauma-Informed Medical Education in the Emergency Medicine Clerkship: Opportunities for Learner-Centered Curricular Development.

An Examination of Trauma-Informed Medical Education in the Emergency Medicine Clerkship: Opportunities for Learner-Centered Curricular Development.