Emergency Medicine Clerkship Research Articles

Tit-For-Tat Strategy for Increasing Medical Student Evaluation Response Rates.

IntroducationIt is essential for faculty to receive feedback on their teaching for the purpose of improvement as well as promotion. It can be challenging to motivate students to provide feedback to preceptors and fill out evaluation forms when not a clerkship requirement. Furthermore, there is concern that making the evaluations a requirement can compromise the quality of the feedback. The objective of this study was to identify an increase in the number of faculty and resident evaluations completed by students rotating through their Emergency Medicine clerkship following the implementation of a tit-for-tat incentive strategy.MethodPrior to the implementation of Tit-for-Tat, students rotating through their emergency medicine clerkship were asked to fill out evaluations of residents and faculty members with whom they worked. These were encouraged but voluntary. Beginning in the 2014–2015 academic year, a tit-for-tat strategy was employed whereby students had to complete a resident or faculty evaluation in order to view the student assessment completed by that resident or faculty preceptor.ResultsStudents submitted 1101 evaluations in the control, with a mean of 3.60 evaluations completed per student and 3.77 evaluations received per preceptor. Following the implementation of tit-for-tat, students submitted 2736 evaluations, with a mean of 8.19 evaluations completed per student and 7.52 evaluations received per preceptor. Both the increase in evaluations completed per student and evaluations received per preceptor were statistically significant with p-value <0.001.ConclusionThe tit-for-tat strategy significantly increased the number of evaluations submitted by students rotating through their emergency medicine clerkship. This has served as an effective tool to increase the overall number of evaluations completed, the number of evaluations each instructor received on average and the proportion of students that completed evaluations. Further work could be done to attempt to better assess the quality of the feedback from these evaluations.

The additional ımpact of simulation based medical training to traditional medical training alone in advanced cardiac life support: a scenario based evaluation

Objectives. The principal aim of medical education is to provide medical student with the fundamental knowledge and re-quired skills that can be specifically used in real-life conditions such as high-quality cardiopulmonary resuscitation (CPR). Traditional medical training (TMT) is an effective method in Advanced cardiac life support (ACLS) training. Simulation-based medical training (SBMT), with the advancements in technology, is a relatively new, but a preferred ACLS training method since it implements a safe educational en-vironment. We planned a scenario-based study to evaluate the additional impact of SBMT to TMT alone in ACLS training. Methods. This before-after type,&nbsp;com-parative,&nbsp;cohort study was performed in a simulation center. One hundred thirty-six 6th grade medical students who took ACLS training with TMT on their emer-gency medicine clerkship were enrolled in 34 teams. All students managed a specific ACLS scenario before and after SBMT with a high-fidelity manikin. All data regarding chest compression, airway management, defibrillation and drug administration were recorded by the sensors of the high-fidelity manikin.Results. Median age was 23 and 51.5% were male. After SBMT, we found significant increases in the successful CPR cycle rate and&nbsp;successful scenario completion rate (60.3%; 61.8%, respectively). Median time to chest compression (Tcc) and defibrillation&nbsp;(Tdef) were&nbsp;significantly decreased after SBMT (1 sec., 1 sec., respectively). For the adequacy of chest compressions, compression depth, recoil, and frequency are all significantly increased after SBMT, 7.0 mm, 6.0 mm and 8.5/min, respectively.&nbsp;Conclusion. SBMT in combination with TMT is a promising ACLS training meth-od when compared to TMT alone.

Tracking Student Mistreatment Data to Improve the Emergency Medicine Clerkship Learning Environment.

IntroductionMedical student mistreatment is a prevalent and significant challenge for medical schools across the country, associated with negative emotional and professional consequences for students. The Association of American Medical Colleges and Liaison Committee on Medical Education have increasingly emphasized the issue of mistreatment in recent years, and medical schools are tasked with creating a positive learning climate.MethodsThe authors describe the efforts of an emergency department (ED) to improve its clerkship learning environment, using a multifaceted approach for collecting mistreatment data and relaying them to educators and clerkship leadership. Data are gathered through end-of-rotation evaluations, teaching evaluations, and an online reporting system available to medical students. Mistreatment data are then relayed to the ED during semi-annual meetings between clerkship leadership and medical school assistant deans, and through annual mistreatment reports provided to department chairs.ResultsOver a two-year period, students submitted a total of 56 narrative comments related to mistreatment or unprofessional behavior during their emergency medicine (EM) clerkship. Of these comments, 12 were submitted in 2015–16 and 44 were submitted in 2016–17. The most frequently observed themes were students feeling ignored or marginalized by faculty (14 comments); students being prevented from speaking or working with patients and/or attending faculty (11 comments); and students being treated in an unprofessional manner by staff (other than faculty, 8 comments).ConclusionThis article details an ED’s efforts to improve its EM clerkship learning environment by tracking mistreatment data and intentionally communicating the results to educators and clerkship leadership. Continued mistreatment data collection and faculty development will be necessary for these efforts to have a measurable effect on the learning environment.

Emergency Medicine Residency Applicant Characteristics Associated with Measured Adverse Outcomes During Residency.

IntroductionNegative outcomes in emergency medicine (EM) programs use a disproportionate amount of educational resources to the detriment of other residents. We sought to determine if any applicant characteristics identifiable during the selection process are associated with negative outcomes during residency.MethodsPrimary analysis consisted of looking at the association of each of the descriptors including resident characteristics and events during residency with a composite measure of negative outcomes. Components of the negative outcome composite were any formal remediation, failure to complete residency, or extension of residency.ResultsFrom a dataset of 260 residents who completed their residency over a 19-year period, 26 (10%) were osteopaths and 33 (13%) were international medical school graduates A leave of absence during medical school (p <.001), failure to send a thank-you note (p=.008), a failing score on United States Medical Licensing Examination Step I (p=.002), and a prior career in health (p=.034) were factors associated with greater likelihood of a negative outcome. All four residents with a “red flag” during their medicine clerkships experienced a negative outcome (p <.001).Conclusion“Red flags” during EM clerkships, a leave of absence during medical school for any reason and failure to send post-interview thank-you notes may be associated with negative outcomes during an EM residency.

Flipping the Classroom in Medical Student Education: Does Priming Work?

IntroductionThe emergency medicine (EM) clerkship curriculum at Los Angeles County + University of Southern California Medical Center includes monthly lectures on pediatric fever and shortness of breath (SOB). This educational innovation evaluated if learning could be enhanced by “priming” the students with educational online videos prior to an in-class session. Factors that impacted completion rates were also evaluated (planned specialty and time given for video viewing).MethodsTwenty-minute videos were to be viewed prior to the didactic session. Students were assigned to either the fever or SOB group and received links to those respective videos. All participating students took a pre-test prior to viewing the online lectures. For analysis, test scores were placed into concordant groups (test results on fever questions in the group assigned the fever video and test results on SOB questions in the group assigned the SOB video) and discordant groups (crossover between video assigned and topic tested). Each subject contributed one set of concordant results and one set of discordant results. Descriptive statistics were performed with the Mann-Whitney U test. Lecture links were distributed to students two weeks prior to the in-class session for seven months and three days prior to the in-class session for eight months (in which both groups included both EM-bound and non-EM bound students).ResultsIn the fifteen-month study period, 64% of students rotating through the EM elective prepared for the in class session by watching the videos. During ten months where exclusively EM-bound students were rotating (n=144), 71.5% of students viewed the lectures. In four months where students were not EM-bound (n=54), 55.6% of students viewed the lectures (p=0.033). Participation was 60.2% when lecture links were given three days in advance and 68.7% when links were given two weeks in advance (p=0.197). In the analysis of concordant scores, the pre-test averaged 56.7% correct, the immediate post-test averaged 78.1% correct, and the delayed post-test was 67.2%. In the discordant groups, the pretest averaged 51.9%, the immediate posttest was 67.1% and the delayed by 68.8%. In the concordant groups, the immediate post-test scores improved by 21.4%, compared with 15.2% in the discordant groups (p = 0.655). In the delayed post-test the concordant scores improved by 10.5% and discordant scores by 16.9 percent (p=0.609). Sixty-two percent of students surveyed preferred the format of online videos with in-class case discussion to a traditional lecture format.ConclusionImmediate post-tests and delayed post-tests improved but priming was not demonstrated to be a statistically superior educational method in this study. Medical student completion of the preparatory materials for the EM rotation session increased when the students were EM-bound. Participation rates were not significantly different when given at two weeks versus three days.

A Novel Approach to Medical Student Peer-assisted Learning Through Case-based Simulations.

IntroductionPeer-assisted learning (PAL) is the development of new knowledge and skills through active learning support from peers. Benefits of PAL include introduction of teaching skills for students, creation of a safe learning environment, and efficient use of faculty time. We present a novel approach to PAL in an emergency medicine (EM) clerkship curriculum using an inexpensive, tablet-based app for students to cooperatively present and perform low-fidelity, case-based simulations that promotes accountability for student learning, fosters teaching skills, and economizes faculty presence.MethodsWe developed five clinical cases in the style of EM oral boards. Fourth-year medical students were each assigned a unique case one week in advance. Students also received an instructional document and a video example detailing how to lead a case. During the 90-minute session, students were placed in small groups of 3–5 students and rotated between facilitating their assigned cases and participating as a team for the cases presented by their fellow students. Cases were supplemented with a half-mannequin that can be intubated, airway supplies, and a tablet-based app (SimMon, $22.99) to remotely display and update vital signs. One faculty member rotated among groups to provide additional assistance and clarification. Three EM faculty members iteratively developed a survey, based on the literature and pilot tested it with fourth-year medical students, to evaluate the course.Results135 medical students completed the course and course evaluation survey. Learner satisfaction was high with an overall score of 4.6 on a 5-point Likert scale. In written comments, students reported that small groups with minimal faculty involvement provided a safe learning environment and a unique opportunity to lead a group of peers. They felt that PAL was more effective than traditional simulations for learning. Faculty reported that students remained engaged and required minimal oversight.ConclusionUnlike other simulations, our combination of brief, student-assisted cases using low-fidelity simulation provides a cost-, resource- and time-effective way to implement a medical student clerkship educational experience.

Comparing the effectiveness of self-directed video tour versus an attending-led tour in Pediatric Emergency Department Orientation

Objectives: Providing an emergency department tour to medical trainees as part of their pediatric emergency medicine clerkship orientation is important in order to teach significant location and safety features. For many years, we provided an attending-led tour, but increased faculty demands on faculty time prompted us to develop a self-directed video-based tour to replace the attending-led tour. This study compares the learning effectiveness between the two methods. Methods: A single-site quasi-experimental design study was conducted to assess knowledge acquisition and satisfaction of medical trainees between two instructional methods (an attending-led tour and a self-directed video-based tour). Groups were assigned an attending-led or self-directed video tour covering identical content. Trainees completed post-tour knowledge acquisition and satisfaction surveys. Mann-Whitney U tests were used for group comparisons of the knowledge acquisition and satisfaction total scores. Spearman correlations were used to look for a relationship between the knowledge acquisition and satisfaction scores. Chi-square and Fisher’s exact tests were used to compare groups on categorical variables. Results: A total of 62 subjects were enrolled; 31 participated in an attending-led tour, and 31 in a video tour. The knowledge acquisition survey (median score 12 vs. 11, p = 0.021) favored the attending-led tour. Total scores for the 5-point satisfaction (median score 47 vs. 40, p = 0.001) and collapsed 3-point satisfaction surveys (median score 30 vs. 29, p = 0.008) also favored the attending-led tour. Conclusions: Although medical trainees favored the attending-led tour over the video tour, the difference was not significant enough to justify terminating the video tour. We believe that this first-time implementation of a self-directed video-based tour is novel. After making further design improvements, we will continue to investigate its plausibility, since it has potential to augment in-person teaching time for educational faculty.

Contributions of Academic Emergency Medicine Programs to U.S. Health Care: Summary of the AAAEM-AACEM Benchmarking Data.

The societal contribution of emergency care in the United States has been described. The role and impact of academic emergency departments (EDs) has been less clear. Our report summarizes the results of a benchmarking effort specifically focused on academic emergency medicine (EM) practices. From October through December 2016, the Academy of Academic Administrators of Emergency Medicine (AAAEM) and the Association of Academic Chairs of Emergency Medicine (AACEM) jointly administered a benchmarking survey to allopathic, academic departments and divisions of emergency medicine. Participation was voluntary and nonanonymous. The survey queried various aspects of the three components of the tripartite academic mission: clinical care, education and research, and faculty effort and compensation. Responses reflected a calendar year from July 1, 2015, to June 30, 2016. Of 107 eligible U.S. allopathic, academic departments and divisions of emergency medicine, 79 (74%) responded to the survey overall, although individual questions were not always answered by all responding programs. The 79 responding programs reported 6,876,189 patient visits at 97 primary and affiliated academic clinical sites. A number of clinical operations metrics related to the care of these patients at these sites are reported in this study. All responding programs had active educational programs for EM residents, with a median of 37 residents per program. Nearly half of the overall respondents reported responsibility for teaching medical students in mandatory EM clerkships. Fifty-two programs reported research and publication activity, with a total of $129,494,676 of grant funding and 3,059 publications. Median faculty effort distribution was clinical effort, 66.9%; education effort, 12.7%; administrative effort, 12.0%; and research effort, 6.9%. Median faculty salary was $277,045. Academic EM programs are characterized by significant productivity in clinical operations, education, and research. The survey results reported in this investigation provide appropriate benchmarking for academic EM programs because they allow for comparison of academic programs to each other, rather than nonacademic programs that do not necessarily share the additional missions of research and education and may have dissimilar working environments.

Understanding the Struggles to Be a Medical Provider: View Through Medical Student Essays

BackgroundThe clinical learning environment helps to shape the professional identity of medical students. This process begins from existing personal identity and is influenced by various factors, including clinical experiences and clinical learning environment. ObjectiveThe purpose of this study was to examine medical students’ reflections as a way to identify and better characterize the modern struggles that medical students face, in order to inform the development of professional identity. MethodsStudents rotating in their emergency medicine clerkship wrote reflections on dilemmas that highlighted common struggles of becoming a doctor. Qualitative analysis was performed to determine common themes from the essays. The research team coded 173 reflections and identified themes and major domains. ResultsThe first domain was Patient–Provider Conflict, including challenging patient (34%), difficult communication (25%), competing priorities between patients’ interest and trainees need to learn (19%), and bias (13%). The second domain was Provider-Specific Issues, such as the “gray zone,” in which there is not a clear standard of practice (29%), end-of-life care (14%), emotional struggle (6%), and fear of litigation (5%). The final domain was Systems Issues, such as cost of care (12%) and role of the emergency department (6%). ConclusionsThe reflections point to a wide variety of challenges that students confront in practice that will contribute to how they develop into physicians.

377TF The Patient Experience: Increasing Medical Student Awareness of Patient-Centered Care

The doctor-patient relationship is the cornerstone of modern medicine. Medicine continues to evolve from a paternalist model to one focused on patient-centered care. Over the last several years, a patient’s satisfaction with her emergency department stay has gained increased importance. Satisfaction is based on a variety of factors, including interactions with staff and being involved in one’s own care decisions. Increased satisfaction is beneficial to patients, physicians, and institutions; patients are happier about the care they receive, physicians are likely to have a sense of greater job fulfilment (thus reducing burnout), and hospitals will likely get higher reimbursements as patient satisfaction scores now affect compensation. Patient-centered care (PCC) has been linked with increased patient satisfaction, better self-management of chronic conditions, and increased efficiency. Though recognized as an integral part of the doctor/patient relationship, communication, and by extension PCC, is often minimized during the third and fourth year of medical school training. An unofficial survey done with third year medical students participating in our emergency medicine (EM) clerkship showed students felt they received little to no formal training on PCC. Introducing a formalized patient-centered care component into the EM clerkship may benefit students by increasing their awareness of PCC, help them hone their communication skills, and lay the groundwork for a career centered around PCC. Upon completing this curriculum, learners should be able to: 1) define PCC and explain its importance in modern health care; 2) describe different ways they can increase PCC in their future patient interactions; 3) discuss how their views towards PCC have changed since the beginning of this learning module. This course is designed for third year medical students participating in the EM clerkship to help increase their understanding of PCC. The module includes two 60-minute classroom sessions, three different reading assignments, a 15-minute standardized patient (SP) encounter followed by a 15-minute debriefing session with the SP and a mentor, a four-hour patient shadowing shift, a module debriefing session, a PCC pre-test, and a PCC post-test. Student evaluation is done on a pass/fail grading scheme and is based on attendance, active participation, and timely completion of assignments. Learners will fill out a PCC pre-test and post-test; differences between these two will be used to determine if students’ views on PCC changed over the course of the rotation. A debriefing session will occur during the second classroom session; students will have the opportunity to discuss how their views on PCC have changed since starting this curriculum, and how it can be improved for future use. An email with the PCC-post survey will be also be sent to learners one year after the curriculum to determine if this module resulted in sustained attitude changes towards PCC. This module can be used to help fill the gap that currently exists in many medical school education curricula and train providers to focus on PCC.

Faculty Evaluations Correlate Poorly with Medical Student Examination Performance in a Fourth-Year Emergency Medicine Clerkship

BackgroundClerkship directors routinely evaluate medical students using multiple modalities, including faculty assessment of clinical performance and written examinations. Both forms of evaluation often play a prominent role in final clerkship grade. The degree to which these modalities correlate in an emergency medicine (EM) clerkship is unclear. ObjectiveWe sought to correlate faculty clinical evaluations with medical student performance on a written, standardized EM examination of medical knowledge. MethodsThis is a retrospective study of fourth-year medical students in a 4-week EM elective at one academic medical center. EM faculty performed end of shift evaluations of students via a blinded online system using a 5-point Likert scale for 8 domains: data acquisition, data interpretation, medical knowledge base, professionalism, patient care and communication, initiative/reliability/dependability, procedural skills, and overall evaluation. All students completed the National EM M4 Examination in EM. Means, medians, and standard deviations for end of shift evaluation scores were calculated, and correlations with examination scores were assessed using a Spearman's rank correlation coefficient. ResultsThirty-nine medical students with 224 discrete faculty evaluations were included. The median number of evaluations completed per student was 6. The mean score (±SD) on the examination was 78.6% ± 6.1%. The examination score correlated poorly with faculty evaluations across all 8 domains (ρ 0.074–0.316). ConclusionFaculty evaluations of medical students across multiple domains of competency correlate poorly with written examination performance during an EM clerkship. Educators need to consider the limitations of examination score in assessing students' ability to provide quality patient clinical care.

Distribution of Honors Grades Across Fourth-year Emergency Medicine Clerkships.

Medical student grades during emergency medicine (EM) rotations are a key factor in resident selection. The variability in grading among EM clerkships is not well understood. The objective was to describe the current grade distribution of fourth-year EM clerkships. This was an observational study at an EM residency program. We identified grade distributions by reviewing the standard letter of evaluation from individuals applying to our residency program for the 2016 match. Descriptive statistics of proportions, standard deviations (SDs), and p-values were calculated. A total of 1,075 applications from 236 individual clerkships were reviewed. Thirty-four programs did not give an honors grade during the previous year. Four of these programs distributed a highest grade of "high pass" and 30 gave only "pass" and/or "fail." Of the remaining 202 programs, the percentage of grades that were given as honors ranged from 1% to 87% with a mean (±SD) of 25% (±17.2%). Of the 202 programs that granted honors grades, 63 (31.2%) sites gave between 1 and 14.9% honors grades, 69 (34.2%) gave 15% to 29.9% honors grades, 27 (13.4%) gave 30% to 44.9% honors grades, and 24 (11.9%) programs granted honors to greater than 45% of their students. Medical schools required an EM rotation at 82 (40.6%) sites. Among these programs, honors grades were given to 24% (±16.7%) of students with a range of 4% to 85% while programs that did not require clerkships gave a mean (±SD) of 26% (±17.5%) with a range of 1% to 87% and a p-value of 0.54. Honor grade distribution varies markedly across U.S. fourth-year EM clerkship sites. Requiring EM clerkships does not affect honor percentages. A minority of sites only give pass/fail grades. Program directors should consider this marked variation in grades when reviewing EM residency applications.

Medical Student Documentation in the Electronic Medical Record: Patterns of Use and Barriers.

IntroductionElectronic health records (EHR) have become ubiquitous in emergency departments. Medical students rotating on emergency medicine (EM) clerkships at these sites have constant exposure to EHRs as they learn essential skills. The Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the Alliance for Clinical Education (ACE) have determined that documentation of the patient encounter in the medical record is an essential skill that all medical students must learn. However, little is known about the current practices or perceived barriers to student documentation in EHRs on EM clerkships.MethodsWe performed a cross-sectional study of EM clerkship directors at United States medical schools between March and May 2016. A 13-question IRB-approved electronic survey on student documentation was sent to all EM clerkship directors. Only one response from each institution was permitted.ResultsWe received survey responses from 100 institutions, yielding a response rate of 86%. Currently, 63% of EM clerkships allow medical students to document a patient encounter in the EHR. The most common reasons cited for not permitting students to document a patient encounter were hospital or medical school rule forbidding student documentation (80%), concern for medical liability (60%), and inability of student notes to support medical billing (53%). Almost 95% of respondents provided feedback on student documentation with supervising faculty being the most common group to deliver feedback (92%), followed by residents (64%).ConclusionClose to two-thirds of medical students are allowed to document in the EHR on EM clerkships. While this number is robust, many organizations such as the AAMC and ACE have issued statements and guidelines that would look to increase this number even further to ensure that students are prepared for residency as well as their future careers. Almost all EM clerkships provided feedback on student documentation indicating the importance for students to learn this skill.

Efficient and Effective Use of Peer Teaching for Medical Student Simulation.

IntroductionSimulation is increasingly used in medical education, promoting active learning and retention; however, increasing use also requires considerable instructor resources. Simulation may provide a safe environment for students to teach each other, which many will need to do when they enter residency. Along with reinforcing learning and increasing retention, peer teaching could decrease instructor demands. Our objective was to determine the effectiveness of peer-taught simulation compared to physician-led simulation. We hypothesized that peer-taught simulation would lead to equivalent knowledge acquisition when compared to physician-taught sessions and would be viewed positively by participants.MethodThis was a quasi-experimental study in an emergency medicine clerkship. The control group was faculty taught. In the peer-taught intervention group, students were assigned to teach one of the three simulation-based medical emergency cases. Each student was instructed to master their topic and teach it to their peers using the provided objectives and resource materials. The students were assigned to groups of three, with all three cases represented; students took turns leading their case. Three groups ran simultaneously. During the intervention sessions, one physician was present to monitor the accuracy of learning and to answer questions, while three physicians were required for the control groups. Outcomes compared pre-test and post-test knowledge and student reaction between control and intervention groups.ResultsBoth methods led to equally improved knowledge; mean score for the post-test was 75% for both groups (p=0.6) and were viewed positively. Students in the intervention group agreed that peer-directed learning was an effective way to learn. However, students in the control group scored their simulation experience more favorably.ConclusionIn general, students’ response to peer teaching was positive, students learned equally well, and found peer-taught sessions to be interactive and beneficial.

Entrustable Professional Activity 10: Recognizing the Acutely Ill Patient-A Delirium Simulated Case for Students in Emergency Medicine.

This simulation case was designed to evaluate the ability of third- and fourth-year emergency medicine clerkship students and acting interns to perform the tasks outlined in the Association of American Medical College's Core Entrustable Professional Activity 10, to "recognize a patient requiring urgent or emergent care and initiate evaluation and management." The overarching goal is to assess medical students' ability to recognize and take steps to stabilize a sick patient. In this case, students encounter a physician, simulated with a high-fidelity manikin, who has suddenly become confused. Students are expected to recognize that he is acutely ill, call for help, and begin the initial steps of resuscitation. Bedside testing reveals hypoglycemia, which students are expected to treat. Further examination, history gathering, and diagnostic tests reveal that the patient is suffering from gram-negative sepsis. Students are evaluated on their ability to recognize signs of serious illness, call for appropriate help, perform critical assessment and treatment tasks, communicate their findings to an attending physician, and determine the appropriate patient disposition. Outcomes are measured using critical action checklists. Initial trials of this case demonstrated its feasibility. All 13 students who have participated in this session have identified all five critical actions. In later iterations, the number of roles was streamlined in order to reduce how many personnel were required. As a result of the very high critical-actions success rates of the first two groups of students tested, our case-specific checklist was revised with the goal of improving its discriminatory power.

Low Back Pain in the Emergency Medicine Department: A Flipped Classroom Module.

Current residency didactic schedules that are built upon hour-long, lecture-based presentations are incongruous with adult learning theory and the needs of millennial generation residents. An alternative to the traditional lecture, the flipped classroom involves viewing a short video lecture at home, followed by an active discussion during class time. This module was developed for emergency medicine residents and rotating medical students without previous training on the subject. The at-home portion of the module was designed to be delivered at home, while the in-class discussion was designed to be carried out over 30-45 minutes during a regularly scheduled didactic time. Small-group size may be determined by faculty availability, though groups of five are optimal. There is no requirement for faculty preparation prior to the in-class session. Associated materials include objectives, the at-home video, a discussion guide for faculty facilitators, a case-based handout for students and residents, and assessment questions. We assessed our module with a pretest, immediate posttest, and the posttest again after 90 days. The mean pretest score was 66%, mean posttest score 76%, and mean retention test score 66%. There was an immediate increase of 10%, which did not remain at 90 days. We developed a flipped classroom module that can be implemented in any emergency medicine residency or clerkship. It addresses the theoretical challenges posed to traditional conference didactics by increasing the focus on problem solving and self-directed learning.

A test of the first course (Emergency Medicine) that is globally available for credit and for free

BackgroundThe WHO has called for the use of computer-aided education to train millions of additional health providers. We herein address this appeal with the first globally available, free, accredited, computer-aided, and peer and mentor-guided course. MethodsThe intervention studied was NextGenU.org's first course, “Emergency Medicine (EM) for Senior Medical Students”, required for the graduating Classes of 2013 at the University of Missouri (UM) and the U.S. Uniformed Services University of the Health Sciences (USUHS). Control groups were the Class of 2012 at USUHS, and students nationally in the Class of 2013. ResultsAs of July 2016, there were over 4,000 registered “NextGenUsers” in 145 countries. USUHS NextGenUsers (n=167) averaged 80.3% vs. USUHS control students’ 80.9% (n=163, p=0.4) on the Society of Academic EM (SAEM) exam, vs. 71.4% nationally (n=415, p<0·0001). UM NextGenUsers (n=35) averaged 71.2% on the SAEM exam vs. 71.4% nationally (n=415, p=0.8). Both EM Clerkship Directors reported good student satisfaction with these asynchronous, competency-based, site-agnostic readings. ConclusionsThis novel model of a free, accredited course is becoming widely used, and has performed as well as some of the world's most-resourced courses.

Creating a contemporary clerkship curriculum: the flipped classroom model in emergency medicine.

BackgroundThe teaching modality of “flipping the classroom” has garnered recent attention in medical education. In this model, the lecture and homework components are reversed. The flipped classroom lends itself to more interaction in “class” and theoretically improved clinical decision-making. Data is lacking for this model for students in emergency medicine clerkships. We trialed the flipped classroom in our fourth-year student clerkship. Our aim was to learn student and faculty facilitator perceptions of the experience, as it has not been done previously in this setting. We evaluated this in two ways: (1) participant perception of the experience and (2) facilitator (EM physician educator) perception of student preparation, participation, and knowledge synthesis.MethodsWith permission from its creators, we utilized an online video series derived from the Clerkship Directors in Emergency Medicine. Students were provided the link to these 1 week prior to the classroom experience as the “homework.” We developed patient cases generated from the videos that we discussed during class in small-group format. Afterward, students were surveyed about the experience using four-point Likert items and free-text comments and also were evaluated by the facilitator on a nine-point scale.ResultsForty-six clerkship students participated. Students deemed the online modules useful at 2.9 (95 % CI 2.7–3.2). Further, they reported the in-class discussion to be of high value at 3.9 (95 % CI 3.8–4.0), much preferred the flipped classroom to traditional lecturing at 3.8 (95 % CI 3.6–3.9), and rated the overall experience highly at 3.8 (95 % CI 3.7–3.9). Based on preparation, participation, and knowledge synthesis, the facilitator judged participants favorably at 7.4 (95 % CI 7.0–7.8). Students commented that the interactivity, discussion, and medical decision-making were advantages of this format.ConclusionsStudents found high value in the flipped classroom and prefer it to traditional lecturing, citing interactivity and discussion as the main reasons. The facilitator also viewed that the students were not only well prepared for the flipped classroom but that they also actively participated in and synthesized knowledge adequately during this experience. This study supports the use of the flipped classroom for EM clerkship students as a valuable, preferable teaching technique.Electronic supplementary materialThe online version of this article (doi:10.1186/s12245-016-0123-6) contains supplementary material, which is available to authorized users.

Clinical Assessment of Medical Students in Emergency Medicine Clerkships: A Survey of Current Practice

BackgroundAssessment practices in emergency medicine (EM) clerkships have not been previously described. Clinical assessment frequently relies on global ratings of clinical performance, or “shift cards,” although these tools have not been standardized or studied. ObjectiveWe sought to characterize assessment practices in EM clerkships, with particular attention to shift cards. MethodsA survey regarding assessment practices was administered to a national sample of EM clerkship directors (CDs). Descriptive statistics were compiled and regression analyses were performed. ResultsOne hundred seventy-two CDs were contacted, and 100 (58%) agreed to participate. The most heavily weighted assessment methods in final grades were shift cards (66%) and written examinations (21–26%), but there was considerable variability in grading algorithms. EM faculty (100%) and senior residents (69%) were most commonly responsible for assessment, and assessors were often preassigned (71%). Forty-four percent of CDs reported immediate completion of shift cards, 27% within 1 to 2 days, and 20% within a week. Only 40% reported return rates >75%. Thirty percent of CDs do not permit students to review individual evaluations, and 54% of the remainder deidentify evaluations before student review. Eighty-six percent had never performed psychometric analysis on their assessment tools. Sixty-five percent of CDs were satisfied with their shift cards, but 90% supported the development of a national tool. ConclusionThere is substantial variability in assessment practices between EM clerkships, raising concern regarding the comparability of grades between institutions. CDs rely on shift cards in grading despite the lack of evidence of validity and inconsistent process variables. Standardization of assessment practices may improve the assessment of EM students.

Using Milestones as Evaluation Metrics During an Emergency Medicine Clerkship

BackgroundThe Accreditation Council for Graduate Medical Education's (ACGME) Milestones presumes graduating medical students will enter residency proficient at Milestone level 1 for 23 skills. The Next Accreditation System now includes Milestones for each postgraduate specialty, and it is unlikely that schools will document every emergency medicine (EM) applicant's EM-specific skills in their performance evaluation. ObjectivesThe goals of this research were to determine if assessment of the Milestones was feasible during a medical student clerkship and examine the proportion of medical students performing at Milestone level 1. MethodsThis study was conducted at a center with Liaison Committee on Medical Education–approved medical training and a 4-year EM residency. Using traditional clerkship, we studied the feasibility of an ACGME EM Milestones–based clerkship assessment. Data led to redesign of the clerkship and its evaluation process, including all level 1 anchor(s) to add “occasionally” (>60%), “usually” (>80%), and “always” (100%) on a Likert scale to on-shift assessment forms. ResultsDuring the feasibility phase (2013–14), 75 students rotated though the clerkship; 55 evaluations were issued and 50 contained the Milestone summary. Eight deficiencies were noted in Milestone 12 and three in Milestone 14. After changes, 49 students rotated under the new evaluation rubric. Of 575 completed on-shift evaluations, 16 Milestone deficiencies were noted. Of 41 institutional evaluations issued, only one student had deficiencies noted, all of which pertained to patient care. All evaluations in this second cohort contained each student's Milestone proficiency. ConclusionsAssessment of the Milestones is feasible. Communication of ACGME EM Milestone proficiency may identify students who require early observation or remediation. The majority of students meet the anchors for the Milestones, suggesting that clerkship assessment with the ACGME EM Milestones does not adequately differentiate students.