Emergency Medicine Faculty Research Articles

Comparative Study of Airway Management Techniques with Restricted Access to Patient Airway

Objective. To determine which airway endotracheal tube (ET), Combitube (CT), or Laryngeal Mask Airway (LMA) has the shortest time to successful ventilation in three nontraditional prehospital airway scenarios. Methods. Prospective randomized cohort study of emergency medicine (EM) residents, faculty EM physicians, andparamedics (EMT-P). Subjects were instructed to place an airway in a mannequin in three scenarios: mannequin supine under a table with head abutting a wall, mannequin sitting upright with access from behind, andmannequin lying on its side with access facing the mannequin. The number of airway placement attempts andtime to successful ventilation were recorded. Results. Twenty-five resident physicians, 9 faculty physicians, and22 EMT-Ps participated. No significant difference was found between the different airways in the number of attempts to successfully ventilate. EMT-Ps demonstrated significantly faster times to successful ventilation for all scenarios versus physicians (e.g., supine scenario with ET, EMT-P median time 57 seconds, physician median time 96 seconds) except for the mannequin lying on its side where there was no significant difference. The time to ventilation for all scenarios was less with the LMA versus ET or CT versus ET, except in the sitting scenario where ET andCT were comparable Conclusions. In this mannequin model of restricted airway access, LMA resulted in significantly faster times to ventilation versus ET andCT in all but one scenario. Further consideration andstudy using airways other than ET are warranted for situations with restricted access to the patient's airway.

Developing a Valid Evaluation for Interpersonal and Communication Skills

The Accreditation Council for Graduate Medical Education requires that residency programs evaluate the acquisition of six general competencies, including Interpersonal and Communication Skills (ICS). To develop a 360-degree method for accomplishing this, a semantic-differentiation matrix for various communication traits for nurses to evaluate physician ICS was developed. The authors sought to determine whether this evaluation method could discriminate between more experienced medical communicators (faculty) and less experienced medical communicators (residents). A 98-item questionnaire measured several communication dimensions by using an eight-element semantic-differentiation scale. In addition, global assessment ratings assessed nursing perceptions of physician ICS skills. This process was repeated for various clinical scenarios. There were 26 nurse evaluators, 19 emergency medicine (EM) residents (EM2 and EM3), and 30 EM faculty. Each physician received five independent evaluations (total, 245 evaluations). All EM residents (EM2 and EM3) were compared with the EM faculty. All eight items on the semantic-differentiation scale were compared. Likewise, the global assessment scores were compared. In every category, the faculty scored higher (Mann-Whitney U: p < 0.001). An evaluation process integrating a semantic-differentiation matrix was applied to various clinical scenarios (as well as global assessment items) and demonstrated discriminatory results. Faculty physicians scored significantly higher than resident physicians. The ability to provide discriminatory results is a requisite in the development of a valid evaluation process. The described semantic-differentiation matrix and global assessment questions may be valid measurements of ICS.

Emergency Cardiology: A Review of Recent Literature

At the University of Maryland Emergency Medicine Residency, members of the emergency medicine faculty each review a different organ system so that the department stays familiar with current literature. I enjoy emergency cardiology, so that is the topic I review. The articles for this review come from a database of more than two dozen American and European cardiology, emergency medicine, and internal medicine journals examined weekly. In addition, with other faculty members, we use several abstract services to ensure that we do not miss important articles from other journals. Altogether, we review several hundred articles, editorials, and reviews each month, which are selected because they reflect some important change in the standard of care. For the most part, these are all original research articles. Two final criteria are relevance to emergency medicine and conclusions that are supported by the data. I present here my most recent review, with topics grouped by common themes: acute coronary syndrome (ACS), congestive heart failure (CHF), syncope, and resuscitation.

Chairperson and Faculty Gender in Academic Emergency Medicine Departments

Despite the influx of female physicians in academic medicine departments, there are a small number of women in faculty and departmental leadership positions in emergency medicine (EM). The objective of this study was to determine if the gender of the chairperson of an academic EM department is associated with the gender of the residency program director (RPD) and gender proportion of its faculty. This was a retrospective analysis of 133 academic EM departments using the Society for Academic Emergency Medicine online residency catalog, program Web site, or e-mail. Main outcome measures were proportion of female EM faculty and gender of the RPD. Data were available for 133 academic departments. Women chaired 7.5% (n = 10) of departments and comprised 22.3% of all faculty and 15.0% (n = 20) of RPD positions. EM departments that were chaired by women had a significantly higher percentage of female faculty compared with those led by men (31% vs. 22%; p = 0.01). Similarly, departments that were chaired by women had a significantly higher proportion of female RPDs compared with those chaired by men (50% vs. 12%; p < 0.01). Compared with departments chaired by men, the RPD was 5.0 times (95% confidence interval = 1.9 to 27.8; p < 0.01) more likely to be a woman if the chairperson was also a woman. An academic EM department was more likely to have a higher proportion of female faculty and a female RPD when the department chairperson was female.

Reliability of a Core Competency Checklist Assessment in the Emergency Department: The Standardized Direct Observation Assessment Tool

A Council of Emergency Medicine Residency Directors task force developed the Standardized Direct Observation Assessment Tool (SDOT), a 26-item checklist assessment tool to evaluate Accreditation Council for Graduate Medical Education resident core competencies by direct observation. Each of the checklist items is assigned to one or more of five core competencies. The objective of this study was to test the interrater measurement properties of the SDOT instrument. Two videos of simulated patient-resident-attending physician encounters were produced. Academic emergency medicine faculty members not involved in the development of the form viewed the two encounters and completed the SDOT for each. Faculty demographic data were collected. Data were collected from 82 faculty members at 16 emergency medicine residency programs. The checklist items were used to generate a composite score for each core competency of patient care, medical knowledge, interpersonal and communication skills, professionalism, and systems-based practice. Univariate analysis demonstrated a high degree of agreement between evaluators in evaluating residents for both videos. Multivariate analysis found no differences in rating by faculty when examined by experience, academic title, site, or previous use of the SDOT. Faculty from 16 emergency medicine residency programs had a high interrater agreement when using the SDOT to evaluate resident core competency performance. This study did not test the validity of the tool. This data analysis is mainly descriptive, and scripted video scenarios may not approximate direct observation in the emergency department.

Reliability of a Core Competency Checklist Assessment in the Emergency Department: The Standardized Direct Observation Assessment Tool

Objectives: A Council of Emergency Medicine Residency Directors task force developed the Standardized Direct Observation Assessment Tool (SDOT), a 26-item checklist assessment tool to evaluate Accreditation Council for Graduate Medical Education resident core competencies by direct observation. Each of the checklist items is assigned to one or more of five core competencies. The objective of this study was to test the interrater measurement properties of the SDOT instrument. Methods: Two videos of simulated patient–resident–attending physician encounters were produced. Academic emergency medicine faculty members not involved in the development of the form viewed the two encounters and completed the SDOT for each. Faculty demographic data were collected. Data were collected from 82 faculty members at 16 emergency medicine residency programs. The checklist items were used to generate a composite score for each core competency of patient care, medical knowledge, interpersonal and communication skills, professionalism, and systems-based practice. Results: Univariate analysis demonstrated a high degree of agreement between evaluators in evaluating residents for both videos. Multivariate analysis found no differences in rating by faculty when examined by experience, academic title, site, or previous use of the SDOT. Conclusions: Faculty from 16 emergency medicine residency programs had a high interrater agreement when using the SDOT to evaluate resident core competency performance. This study did not test the validity of the tool. This data analysis is mainly descriptive, and scripted video scenarios may not approximate direct observation in the emergency department.

The Peer Review Process as an Educational Tool for Emergency Medicine Residents and Faculty

The Peer Review Process as an Educational Tool for Emergency Medicine Residents and Faculty

The Society for Academic Emergency Medicine's 2004–2005 Emergency Medicine Faculty Salary and Benefit Survey

To report on the sixth survey of the Society for Academic Emergency Medicine (SAEM) of emergency medicine faculty salaries, benefits, work hours, and department demographics for all programs accredited by the Residency Review Committee for Emergency Medicine (RRC-EM). Data represent compensation paid for the 2004-2005 academic year. Responses were collected by SAEM, and blinded program and individual faculty data were entered into a customized version of a relational database program with a built-in statistical package. Salary data were sorted by criteria such as program region, faculty title, American Board of Emergency Medicine certification, academic rank, years since completing residency, program size, and whether data were reported to the American Association of Medical Colleges (AAMC). Demographic data were analyzed with regard to numerous criteria including department staffing levels, emergency department (ED) volumes, ED length of stay, department income sources, salary incentive components, research funding, and specific type and value of fringe benefits offered. Data were compared with previous SAEM studies. Sixty-one of 132 (46%) accredited programs responded, yielding data on 1,213 full-time faculty from all four AAMC regions. Mean salaries were reported as follows: all faculty, 189,848 dollars; first-year faculty, 153,855 dollars; programs reporting data to AAMC, 183,605 dollars; programs not reporting data to AAMC, 204,383 dollars; core faculty, 197,259 dollars; and noncore faculty, 164,215 dollars. Mean salaries as reported by AAMC region were as follows: Northeast, 192,864 dollars; South, 182,768 dollars; Midwest, 192,224 dollars; and West, 195,732 dollars. Full-time emergency medicine residency program faculty are reported to be working an average of 1,032 total clinical hours per year. Workweeks average 22 clinical hours per week and 22 nonclinical hours per week, with 5.1 weeks of time off per year. Reported salaries for full-time emergency medicine residency faculty continue to rise overall but fell for the first time in one region (the Midwest). Academic rank continues to correlate directly with salary. Fellowship training continues to show a negative correlation with salary. Significant regional differences in salaries have been present in all six SAEM surveys.

The Society for Academic Emergency Medicine's 2004–2005 Emergency Medicine Faculty Salary and Benefit Survey

The Society for Academic Emergency Medicine's 2004–2005 Emergency Medicine Faculty Salary and Benefit Survey

Gender-based Differences in Emergency Medicine Faculty Compensation and Working Conditions

Gender-based Differences in Emergency Medicine Faculty Compensation and Working Conditions

A comparison between the efficacy of lectures given by emergency and non-emergency physicians in an international emergency medicine educational intervention

The Tuscan Emergency Medicine Initiative is an international collaboration designed to create a sustainable emergency medicine training and qualification process in Tuscany, Italy. Part of the program involves training all emergency physicians currently practicing in the region. This qualification process includes didactic lectures, clinical rotations and practical workshops for those with significant emergency department experience. Lectures in the didactic portion were given by both emergency medicine (EM) and non-EM faculty. We hypothesized that faculty who worked clinically in EM would give more effective lectures than non-EM faculty. Fifty-one emergency physicians from the hospitals surrounding Florence completed the course, which included 48 one-hour lectures. Twenty lectures were given by practicing emergency physicians and 28 were given by non-EM faculty. Participants completed an evaluation at the end of each session using a 5-point Likert scale describing the pertinence of the lecture to EM, the efficacy and clarity of the presentation, the accuracy of the information and the didactic ability of the lecturer. A mean of 38.5 evaluations was completed for each lecture. Every factor was significantly higher for lectures given by EM faculty: the pertinence of the lecture to EM (4.46 vs. 4.16, p < 0.001), the efficacy of the faculty (4.10 vs. 3.91, p < 0.001), the accuracy of the lecture content (4.16 vs 3.96, p < 0.001), and the didactic ability of the instructors (4.02 vs. 3.85, p = 0.001). When teaching EM, evaluations of lectures in this training intervention were higher for lectures given by EM faculty than by non-EM faculty.

Anechoic Stripe Size Influences Accuracy of FAST Examination Interpretation

Accurate and precise interpretations of Focused Assessment with Sonography for Trauma (FAST) findings are important factors in managing trauma patients. The objectives were to analyze the influence of anechoic stripe (AS) size on interpretation accuracy by emergency physicians (EPs) and to assess the precision of FAST examination interpretation as a function of EP FAST experience. A prospective comparison study of FAST examination interpretation by 11 emergency medicine faculty (FAC), nine community attending EPs (ATT), and nine senior emergency medicine residents (RES) was conducted; these physicians were then divided into more experienced and less experienced cohorts to assess precision. Participants interpreted video recordings of the four standard views from five FAST examinations (20 total video clips); each examination contained views with various AS sizes. Accuracy of FAST examination interpretation was calculated for each group stratified by size of AS. Precision (reproducibility) of FAST examination interpretation was assessed by calculating kappa values. With large, moderate, or no AS, no significant differences in accuracy were found between groups. For small AS, significant differences in accuracy were found between the ATT and RES groups and between the combined FAC + ATT group and the RES group. Kappa was good to excellent when the nth and the (n + 1)th experienced physicians in the more experienced cohort were compared. kappa values reflected that the more experienced cohort was more precise than the less experienced cohort. AS size visible on FAST examinations and EP experience level with FAST examination interpretation exerted a significant influence on the interpretation accuracy of videotaped FAST examinations. In addition, precision was enhanced by increased EP experience with FAST.

Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques

Objective Tracheal necrosis, stenosis, and rupture may result from overinflated endotracheal tube cuffs (ETTcs). We sought to determine the ability of faculty emergency medicine (EM) physicians to safely inflate ETTc as well as to estimate pressure of previously inflated ETTc. Methods Using a previously tested tracheal simulation model, we assessed EM physician inflation of ETTc pilot balloons. Participants also palpated the pilot balloon of 9 ETTc inflated to pressures ranging from extremely low to extremely high in a random order and reported their estimate of pressure. Results We sampled 41 faculty EM physicians from 5 EM residency programs. Using palpation, participants were only 22% sensitive detecting overinflated ETTc. The average ETTc pressure produced by inflation was more than 93 cm H 2O (normal, 15-25 cm H 2O). Conclusions Participants were unable to inflate ETTc to safe pressures or estimate pressure of ETTc by palpation. Clinicians should consider using devices to facilitate safe inflation and accurate measurement of ETTc pressure.

What Do Emergency Medicine Learners Want from Their Teachers? A Multicenter Focus Group Analysis

To the best of the authors' knowledge, there are no reports describing what learners believe are good emergency medicine (EM) teaching practices. EM faculty developers are compromised by this lack of knowledge about what EM learners appreciate in their teachers. To determine what Canadian EM learners consider to be good prerequisites and strategies for effective teaching in the emergency department (ED). Clinical clerks and residents from the Canadian College of Family Physicians, Emergency Medicine certification [CCFP(EM)] fellowship program, the Royal College of Physicians and Surgeons of Canada, Emergency Medicine certification [FRCP(EM)] fellowship program, and off-service programs from all five Ontario medical schools participated in monitored focus-group sessions. Conversations were recorded, transcribed by a third party, and coded by two independent assessors using standard grounded theory methods. The text was categorized based on the final code into basic themes and specific qualifiers, which were then sorted by frequency of mention in the focus groups. Results are presented in descriptive fashion. Twenty-eight learners participated. They identified 14 major principles for good EM teaching, and a further 30 specific qualifiers. The top five principles were: "has a positive teacher attitude," "takes time to teach," "uses teachable moments well," "tailors teaching to the learner," and "gives appropriate feedback." Agreement on classification of ideas was 86%. Learners are sensitive to the constraints of the ED teaching environment, and have consistent views about good ED teaching practices. Among 14 general principles identified, "takes time to teach," "gives feedback," "tailors teaching to the learner," "uses teachable moments," and "has a good teacher attitude" were the most commonly reported.

What Do Emergency Medicine Learners Want from Their Teachers? A Multicenter Focus Group Analysis

Background: To the best of the authors' knowledge, there are no reports describing what learners believe are good emergency medicine (EM) teaching practices. EM faculty developers are compromised by this lack of knowledge about what EM learners appreciate in their teachers. Objectives: To determine what Canadian EM learners consider to be good prerequisites and strategies for effective teaching in the emergency department (ED). Methods: Clinical clerks and residents from the Canadian College of Family Physicians, Emergency Medicine certification [CCFP(EM)] fellowship program, the Royal College of Physicians and Surgeons of Canada, Emergency Medicine certification [FRCP(EM)] fellowship program, and off-service programs from all five Ontario medical schools participated in monitored focus-group sessions. Conversations were recorded, transcribed by a third party, and coded by two independent assessors using standard grounded theory methods. The text was categorized based on the final code into basic themes and specific qualifiers, which were then sorted by frequency of mention in the focus groups. Results are presented in descriptive fashion. Results: Twenty-eight learners participated. They identified 14 major principles for good EM teaching, and a further 30 specific qualifiers. The top five principles were: “has a positive teacher attitude,”“takes time to teach,”“uses teachable moments well,”“tailors teaching to the learner,” and “gives appropriate feedback.” Agreement on classification of ideas was 86%. Conclusions: Learners are sensitive to the constraints of the ED teaching environment, and have consistent views about good ED teaching practices. Among 14 general principles identified, “takes time to teach,”“gives feedback,”“tailors teaching to the learner,”“uses teachable moments,” and “has a good teacher attitude” were the most commonly reported.

A Multiphase Disaster Training Exercise for Emergency Medicine Residents: Opportunity Knocks

Disaster planning is a core curriculum requirement for emergency medicine (EM) residency programs. Few comprehensive training opportunities in disaster planning incorporating the appropriate competencies have been reported. To design, pilot, and evaluate a combination interactive Web-based disaster planning curriculum and real-time multidisciplinary full-scale disaster exercise. Residents were assigned to groups led by a faculty mentor. Each group used an Internet-based platform to review the literature pertaining to their component of a disaster plan. The groups then used the platform to redesign an existing institutional disaster plan. Finally, they implemented their disaster plan for 80 simulated casualties resulting from a police, fire department, and emergency medical services multiple-casualty rescue exercise. All health professions then participated in a joint debriefing session. All aspects of the program were supervised by specialty EM faculty, and the exercise was evaluated using a five-point Likert scale with specific anchored descriptors. Sixteen residents and 17 faculty members participated in the exercise. Trained volunteers and high-fidelity simulations represented casualties varying in age from 6 months to 65 years, and in severity from ambulatory to moribund. Residents found the exercise enjoyable (4.9/5), relevant (4.6/5), and educational (4.8/5). Emergency medicine residency programs can benefit from participating in high-quality medical disaster exercises coordinated with local disaster response agencies. Residents report high satisfaction and learning from realistic simulations of disasters, and from collaboration with other community services.

Faculty Development

As emergency medicine faculty, we are called upon to be skilled in a great number of different areas. Residency training prepares us to be knowledgeable clinicians, skillful at procedures, good communicators, and effective at multitasking. Rarely, however, does it prepare us as educators or in the nuances of career advancement in an academic environment. Faculty development is a term used to describe both our growth as clinician–educators and navigation of the tenure and promotion process. An important role of medical student educators is to assist in preparing themselves and the faculty to be good teachers. In addition, we all hope to have successful careers as clinician–educators. The goal of this report is 2‐fold: to provide a guide for faculty to advance their skills as educators and to help teaching faculty to advance their academic career. The first section of this report presents an approach to becoming a skilled educator, and the second section focuses on career development as an educator in an academic setting.

Faculty Development

As emergency medicine faculty, we are called upon to be skilled in a great number of different areas. Residency training prepares us to be knowledgeable clinicians, skillful at procedures, good communicators, and effective at multitasking. Rarely, however, does it prepare us as educators or in the nuances of career advancement in an academic environment. Faculty development is a term used to describe both our growth as clinician-educators and navigation of the tenure and promotion process. An important role of medical student educators is to assist in preparing themselves and the faculty to be good teachers. In addition, we all hope to have successful careers as clinician-educators. The goal of this report is 2-fold: to provide a guide for faculty to advance their skills as educators and to help teaching faculty to advance their academic career. The first section of this report presents an approach to becoming a skilled educator, and the second section focuses on career development as an educator in an academic setting.

What Characteristics of Applicants to Emergency Medicine Residency Programs Predict Future Success as an Emergency Medicine Resident?

Program directors of emergency medicine (EM) residencies attempt to select candidates who will subsequently perform well as residents. This study was undertaken to identify characteristics available at the time of application to an EM residency that predict future success in residency. The EM faculty at the University of California San Diego (UCSD) completed a one-time confidential assessment of EM residents on performance in residency at the time of graduation. The faculty member compared the graduate with all residents (both EM and non-EM) with whom the faculty member had previously worked using the five-point scale: > or =90th percentile, 70th-89th percentile, 50th-69th percentile, 30th-49th percentile, or < 30th percentile. Descriptive statistics, ordinal logistic regression (OLR), classification and regression tree (CART) analysis, and multiple additive regression tree (MART) analysis were used to find predictors for each of the outcome variables. Fifty-four graduates were evaluated. The medical school attended (MSA) was the strongest predictor of overall performance in residency in all regression models. OLR showed that MSA and "distinctive factors" (being a championship athlete, medical school officer, etc.) were significant predictors and may deserve greater weighting in the selection process. The most robust MART model demonstrated that MSA, dean's letter of recommendation, and distinctive factors had the most impact on overall performance in an EM residency. Using regression modeling, it may be possible to predict future resident performance from characteristics contained in residency applications. Applicants from top-tier medical schools and those with distinctive talents were more successful in the UCSD EM residency.

Emergency medicine teaching faculty perceptions about formal academic sessions: “What’s in it for us?”

Little is known about factors affecting emergency physician attendance at formal academic teaching sessions or what emergency physicians believe to be the benefits derived from attending these activities. To determine what factors influence emergency medicine faculty attendance at formal academic rounds, what benefits they derive from attendance, and what differences in perceptions there are between full-time clinical and part-time clinical academic faculty. A survey was sent to all emergency physicians with academic appointments at one institution. Responses were tabulated dichotomously (yes/no) for checklist answers and analyzed using a 2-person grounded theory approach for open answers based on an a priori analysis plan. Differences between full-time and part-time faculty were compared using the chi-squared test for significance. Response rate was 73.8% (48/65). Significant impediments to attendance included clinical responsibilities (75%), professional responsibilities (52.1%), personal responsibilities (33.3%), location (31.2%) and time (27.1%). Perceived benefits of attending rounds were: continuing medical education, social interaction, teaching opportunities, interaction with residents, comparing one's practice with peers, improving teaching techniques, and enjoyment of the format. There were no statistically significant differences between groups' responses. Emergency physicians in our study attend formal teaching sessions infrequently, suggesting that the perceived benefits do not outweigh impediments to attendance. The single main impediment, competing responsibilities, is difficult to modify for emergency physicians. Strategies to increase faculty attendance should focus on enhancing the main perceived benefits: continuing medical education, social interaction and educational development. Faculty learn from themselves and from residents during formal teaching sessions.