Emergency Medicine Programs Research Articles

Three- vs. Four-Year Emergency Medicine Training Programs.

Postgraduate training in emergency medicine (EM) varies in length among different programs. This fact creates a dilemma for applicants to the specialty of EM and prevents EM educators from reaching a consensus regarding the optimal length of training. Historically, EM training existed in the postgraduate year (PGY) 1-3, 2-4, and 1-4 formats, until the PGY 2-4 program became obsolete in 2011-2012. Currently, three-quarters of EM programs follow the PGY 1-3 format. In this article, we clarify for the applicants the main differences between the PGY 1-3 and PGY 1-4 formats. We also discuss the institutional, personal, and graduate considerations that explain why an institution or an individual would choose one format over the other.

Standardized Letters of Concern and Remediation Contracts: Templates for Program Directors.

Remediation of the struggling resident is a universal phenomenon, and the majority of program directors will remediate at least 1 resident during their tenure. The goal of this project was to create a standardized template for program directors to use at all stages of remediation. Between 2017 and 2018, the Council of Residency Directors in Emergency Medicine (CORD-EM) Remediation Committee searched for best practices in the medical literature and compiled a survey that was e-mailed to the CORD-EM listserv. After reviewing all information, a standardized remediation contract was created, reviewed by legal counsel, and distributed to members. Forty-two percent (110 of 263) of program directors or assistant program directors on the CORD-EM listserv answered the initial survey and provided guidance on current remediation practices. The committee created formal and informal standard remediation contracts as both fillable templates and alterable documents. These were reviewed by CORD-EM general legal counsel and approved by the CORD-EM Board of Directors for distribution. The project took approximately 20 hours to complete over 8 months and involved a cost of $480 for legal fees. With program director input and legal counsel review, the CORD-EM Remediation Committee produced standardized remediation contracts, which can be used by all emergency medicine programs after comparison to local institutional policy and local legal review. This process was feasible and can be replicated by other specialties.

193 Development of Learning Objectives for a Standardized Pediatric Emergency Medicine Curriculum for the African Federation for Emergency Medicine

Few African countries have dedicated emergency medicine training, and none have a pediatric emergency medicine (PEM) program. However, many countries have a high burden of pediatric patients, and as many as 25% of those patients have high-acuity disease. The African Federation for Emergency Medicine (AFEM) is developing an open-access, core curricular package for pediatric emergency medicine to meet this need. Our objective was to implement group consensus methodology to develop learning objectives for this curriculum. A group of PEM and global health experts developed a comprehensive list of objectives based upon a needs assessment conducted in Tanzania in 2017. A second panel of experts met at the African Conference on Emergency Medicine in Rwanda in November 2018 and employed a modified Delphi process to attain consensus regarding the list of objectives. A semi-anonymous format of voting was used to allow for balanced input. Consensus was defined as >70% approval. Any objective not meeting at least 30% approval was immediately removed; an objective meeting 30-70% approval was discussed and edited as needed, and repeat voting determined final approval rate. The objectives were evaluated for appropriateness for 3 previously defined provider groups: (1) out-of-hospital providers, nurses, (2) medical officers, senior nurses, and (3) residents, specialists, consultants. There were 7 voting participants in the modified Delphi process. All Tier 3 objectives (79) met consensus. One objective from Tier 2 was revised under consensus, and one objective was added with consensus agreement to create a list of 42 objectives. Five objectives in Tier 1 did not initially achieve consensus, 4 of which required revisions, for a final list of 30 objectives. A group consensus process resulted in the development of a list of 161 objectives for a pediatric emergency medicine curriculum for multiple levels of practitioners in African settings. These objectives will guide development of the AFEM pediatric emergency medicine curriculum, which will advance pediatric emergency care competency across Africa.

109 Social Emergency Medicine: Pakistan Perspective

WHO defines Social Determinants of Health (SDH) as “conditions in which people are born, grow, live, work and age, shaped by the distribution of money, power and resources at global, national and local levels.” The term “Social Emergency Medicine (SEM)” caters to the concept that emergency departments (EDs) provide resource intensive, critical care to high risk patients but also address social health determinants. In USA, ACEP has an established SEM section .with Social Medicine and Population Health Interest Group at SAEM. Fellowships in SEM also focus on incorporation of the patient’s social context into Emergency management. The Indus Hospital (TIH) is a 212 bed, tertiary care center, providing quality treatment, free of cost in Pakistan where social determinants of health result in multiple ED visits, bounce back and loss of income for both the patient and care giver. TIH is in the unique position to address SDH and affect masse, resulting in improved patient outcome. The specialty of emergency medicine (EM) in Pakistan is in its early years and lack of well established primary care has traditionally placed a huge burden on EDs. Preventive role of ED is not taught at undergraduate or postgraduate level. Bedside application of social determinants of health and using it to reach out into the community with well formulated plans will reduce the burden of disease and cost of managing it. The introduction of SEM at national level will develop emergency physicians cognizant of social determinants of health and better trained to address them. a) Collection of data on social determinants of health through ED centered studies with interventions to show improvement in SDH over one year. This data shall be shared with other hospitals in Pakistan running EM programs and presented to local and international donors to secure grants. b) US based fellowship programs in SEM will be approached for collaborative partnerships with the ED at TIH. With our history of collaborative programs, rotating international EM faculty can be engaged to provide training to our residents. c) The College of Physicians and Surgeons (CPSP), the national residency accrediting body has a well-defined EM curriculum. We have designed a three-month module based on SEM which will be used to teach and train our residents as a pilot. It will be presented to CPSP as a proposal to incorporate into the EM curriculum. This will ensure that all Emergency physicians being trained across Pakistan receive a formal education in SEM. d) Similar ED based programs that have met with success can be used as reference and models to develop our own programs. Examples of Chicago based “Better Health through Housing” and “Project HEAL (HIV & HCV Screening, Education, Awareness, Linkage to Care) can be used to develop local programs focused on our social determinants of health. The concept of SEM is the need of the day in LMIC like Pakistan where recognizing and preventing progression of disease and the factors that influence it can be cost-effective. Resources in health care, especially in the public sector are scarce and their wise utilization has to be practiced. By focusing on the vulnerable population presenting to EDs, it is hoped that social determinants of heath can be improved and this can result in shifting the paradigm from cure to prevention

Combined Residency Programs in Emergency Medicine.

There are currently 5 combined residencies in emergency medicine (EM), namely EM/pediatrics, EM/internal medicine, EM/internal medicine/critical care, EM/family medicine and EM/anesthesiology. These combined programs vary from 5-6years in length. Like categorical programs, the decision to enter a 5- or 6-year program should be an informed and comprehensive decision. We describe the history and current status of the combined EM programs, discuss the process of applying to a combined EM program, describe the life of combined EM residents, and explore common career opportunities available to combined EM program graduates.

Rapid Response and Cardiac Arrest Teams: A Descriptive Analysis of 103 American Hospitals.

Descriptive cross-sectional, internet-based survey. Cohort of preidentified clinicians involved in their hospital's adult rapid response system across the United States. Clinicians who had been identified by study team members using personal and professional contacts over a 7-month period from June 2018 to December 2018. An 80-item survey was developed by the investigators. It sought information on the afferent (identification and notification of providers) and efferent (response of providers to patient) limbs of the rapid response system, as well as management of patients post in-hospital cardiac arrest. One-hundred fourteen surveys were distributed. Of these, 109 (96%) were completed. Six were duplicates and were excluded, leaving a total of 103 surveys from 103 hospitals in 30 states. Seventy-six percent of hospitals were academic, 30% were large hospitals (> 750 inpatient beds), and 58% had large ICUs (> 50 ICU beds). We found wide variation in the structure and function in both the afferent and efferent limbs of the rapid response system. The majority of hospitals had a rapid response team and a cardiac arrest team. Most rapid response teams contained a provider, a critical care nurse, and a respiratory therapist. In hospitals with training programs in internal medicine, anesthesia, emergency medicine, or critical care, 45% of rapid response teams and 75% of cardiac arrest teams were led by trainees, with inconsistent attending presence. Targeted temperature management and coronary catheterization were widely used post in-hospital cardiac arrest, but indications varied considerably. We have demonstrated substantial variation in the structure and function of rapid response systems as well as in management of patients during and after in-hospital cardiac arrest.

Training in the Management of Psychobehavioral Conditions: A Needs Assessment Survey of Emergency Medicine Residents.

Mental health-related ED visits are increasing. Despite this trend, most emergency medicine (EM) residency programs devote little time to psychiatry education. This study aimed to identify EM residents' perceptions of training needs in emergency psychiatry and self-confidence in managing patients with psychobehavioral conditions. A needs assessment survey was distributed to residents at 15 Accreditation Council for Graduate Medical Education-accredited EM programs spanning the U.S. Survey items addressed amount and type of training in psychiatry during residency, perceived training needs in psychiatry, and self-confidence performing various clinical skills related to emergency psychiatric care. Residents used a 5-point scale (1=nothing; 5=very large amount) to rate their learning needs in a variety of topic areas related to behavioral emergencies (e.g., medically clearing patients, substance use disorders). Using a scale from 0 to 100, residents rated their confidence in their ability to independently perform various clinical skills related to emergency psychiatric care (e.g., differentiating a psychiatric presentation from delirium). Of the 632 residents invited to participate, 396 (63%) responded. Twelve percent of respondents reported completing a psychiatry rotation during EM residency. One of the 15 participating programs had a required psychiatry rotation. Residents reported that their program used lectures (56%) and/or supervised training in the ED (35%) to teach residents about psychiatric emergencies. Most residents reported minimal involvement in the treatment of patients with psychiatric concerns. The majority of residents (59%) believed that their program should offer more education on managing psychiatric emergencies. Only 14% of residents felt "quite" or "extremely" prepared to treat psychiatric patients. Overall, residents reported the lowest levels of confidence and highest need for more training related to counseling suicidal patients and treating psychiatric issues in special populations (e.g., pregnant women, elderly, and children). Most EM residents desire more training in managing psychiatric emergencies than is currently provided.

Keeping busy learners informed: email is most useful for medical residents!

Educators need to ensure trainees have access to the rotation orientation information they need in the most effective way possible. We wanted to find the best method to distribute this information. We provided post-graduate medical trainees rotating through the Pediatric Emergency Medicine program at the Children's Hospital of Eastern Ontario in Ottawa, Canada, the regular rotation information package three ways: email, online, and paper. We surveyed them to find out which method(s) they used and which they found most useful. All trainees were able to access the electronic orientation package via email and most found this method useful. Most also found the paper package distributed at the orientation helpful. Few accessed the online wiki site. Using email is efficient and effective and can save both the time and cost of producing paper packages. The wiki site was not used frequently in our cohort, but may be worth future exploration.

A National Study of Longitudinal Consistency in ACGME Milestone Ratings by Clinical Competency Committees: Exploring an Aspect of Validity in the Assessment of Residents' Competence.

To investigate whether clinical competency committees (CCCs) were consistent in applying milestone ratings for first-year residents over time or whether ratings increased or decreased. Beginning in December 2013, the Accreditation Council for Graduate Medical Education (ACGME) initiated a phased-in requirement for reporting milestones; emergency medicine (EM), diagnostic radiology (DR), and urology (UR) were among the earliest reporting specialties. The authors analyzed CCC milestone ratings of first-year residents from 2013 to 2016 from all ACGME-accredited EM, DR, and UR programs for which they had data. The number of first-year residents in these programs ranged from 2,838 to 2,928 over this time period. The program-level average milestone rating for each subcompetency was regressed onto the time of observation using a random coefficient multilevel regression model. National average program-level milestone ratings of first-year residents decreased significantly over the observed time period for 32 of the 56 subcompetencies examined. None of the other subcompetencies showed a significant change. National average in-training examination scores for each of the specialties remained essentially unchanged over the time period, suggesting that differences between the cohorts were not likely an explanatory factor. The findings indicate that CCCs tend to become more stringent or maintain consistency in their ratings of beginning residents over time. One explanation for these results is that CCCs may become increasingly comfortable in assigning lower ratings when appropriate. This finding is consistent with an increase in confidence with the milestone rating process and the quality of feedback it provides.

Preventing Today's GME Disasters: Lessons Learned From a Failed Contract Renewal.

Preventing Today's GME Disasters: Lessons Learned From a Failed Contract Renewal.

Not Just Hocus POCUS: Implementation of a Point of Care Ultrasound Curriculum for Internal Medicine Trainees at a Large Residency Program.

In 2018, the American College of Physicians formally acknowledged the importance of Point of Care Ultrasound (POCUS) to the practice of internal medicine (IM). For the military internist, POCUS training is critical for care of the trauma patient in austere environments, mass casualty events and natural disasters. While emergency medicine and critical care training programs have adopted POCUS education, few IM programs have integrated POCUS into their core curricula. We designed and implemented an iterative POCUS curriculum for trainees at a large military IM residency program over a two-year period. In collaboration with our critical care and simulation departments, we developed a pilot curriculum consisting of five, 60-minute courses offered on a voluntary basis at monthly intervals throughout 2017. Based on the pilot's success we incorporated a POCUS curriculum into the core academics received by all IM trainees during the 2017-2018 academic year. Trainees attended seven, 3-hour sessions during their scheduled academic time taught by subspecialists with POCUS expertise in an on-site simulation center. Baseline surveys and knowledge assessment examinations were administered during orientation and repeated at the end of the academic year. Comparison of results before and after the POCUS curriculum was the primary outcome evaluated. Intervention #1: Pilot, 2016-2017 Academic Year45 trainees attended at least one course with an average of 1.8 sessions per trainee. Baseline survey data showed 91% of trainees believe POCUS is quite or extremely beneficial for their patients, but 73% feel slightly or not at all confident in POCUS knowledge. The pre-test mean and median scores were 71% and 77% respectively, which both increased to a post-test mean and median of 81%. Post-test mean percentage correct for trainees attending 1, 2, or 3 courses was 74%, 82%, and 91% respectively. Intervention #2: Incorporation of POCUS into Core Academics, 2017-2018 Academic YearAll 75 trainees participated in training with an average of 3.77 sessions attended per trainee. Survey analysis revealed significant improvement in confidence of performing ultrasound-guided procedures (p = 0.0139), and a 37% absolute increase in respondents who anticipate using ultrasound in their clinical practice (p = 0.0003). The mean pre-test score was 67.8% with median of 63.6% while mean and median post-test scores were 82.1% and 81.8%, with an absolute improvement of 14.3% and 18.2% respectively (p = 0.0004). A structured POCUS curriculum was successfully incorporated at a large multiservice military IM residency program, with demonstrated retention of knowledge, improved confidence in performance of ultrasound guided invasive procedures, and increased interest in the use of POCUS in future clinical practice. Similar programs should be implemented across all IM programs in military graduate medical education to enhance operational readiness and battlefield care.

Faculty development in the age of competency-based medical education: A needs assessment of Canadian emergency medicine faculty and senior trainees.

The Royal College of Physicians and Surgeons of Canada (RCPSC) emergency medicine (EM) programs transitioned to the Competence by Design training framework in July 2018. Prior to this transition, a nation-wide survey was conducted to gain a better understanding of EM faculty and senior resident attitudes towards the implementation of this new program of assessment. A multi-site, cross-sectional needs assessment survey was conducted. We aimed to document perceptions about competency-based medical education, attitudes towards implementation, perceived/prompted/unperceived faculty development needs. EM faculty and senior residents were nominated by program directors across RCPSC EM programs. Simple descriptive statistics were used to analyse the data. Between February and April 2018, 47 participants completed the survey (58.8% response rate). Most respondents (89.4%) thought learners should receive feedback during every shift; 55.3% felt that they provided adequate feedback. Many respondents (78.7%) felt that the ED would allow for direct observation, and most (91.5%) participants were confident that they could incorporate workplace-based assessments (WBAs). Although a fair number of respondents (44.7%) felt that Competence by Design would not impact patient care, some (17.0%) were worried that it may negatively impact it. Perceived faculty development priorities included feedback delivery, completing WBAs, and resident promotion decisions. RCPSC EM faculty have positive attitudes towards competency-based medical education-relevant concepts such as feedback and opportunities for direct observation via WBAs. Perceived threats to Competence by Design implementation included concerns that patient care and trainee education might be negatively impacted. Faculty development should concentrate on further developing supervisors' teaching skills, focusing on feedback using WBAs.

A National Evaluation of Scholarly Activity Requirement in Osteopathic EM Residency Programs: Survey of EM Program Directors.

The objectives of the study were to determine the percentage of osteopathic emergency medicine (EM) residencies that require an original research project to meet the American Osteopathic Association requirement, describe the resources available to the residents and faculty members to complete their projects, and determine resident and faculty research productivity. This was a cross-sectional online survey of program directors from osteopathic EM residency programs. Participants were asked about demographics and specifics related to their program's research curriculum, which included resources, outcomes, and challenges. The response rate was 48.21% (27/56) of program directors from EM residencies. The majority (82.77%) of respondents were from a community-based EM program, had a requirement that a research project be completed before graduation from residency (87.5%), and did not have a research associate program to assist in recruiting patients (83.33%). A physician research director was noted to lead the department in 53.57% of respondents, whereas 70.83% noted having a statistician on staff. A total of 2.91% of program faculty had received federal grant funding, and 13.88% had a research study indexed in PubMed. EM programs that had a physician-led research director were more likely to have core faculty with federal funding, articles indexed in PubMed, residents who submit their research for publication, and residents with competitive grants, as compared with programs without a research director. Program directors noted that analyzing data, designing a study, and generating a hypothesis were the biggest challenges to conducting research in the residency. Osteopathic EM residencies significantly differ from their allopathic counterparts in their research curriculum, capabilities, and outcomes.

MP18: Addressing unrealistic expectations: a novel transition to discipline curriculum in emergency medicine

Innovation Concept: Emergency medicine (EM) programs have restructured their training using a Competence by Design model. This model emphasizes entrustable professional activities (EPAs) that residents must fulfill before advancing in their training. The first EPA (EPA 1) for the transition to discipline (TTD) stage involves managing the unstable patient. Data from the University of Toronto (U of T) program suggests residents lack enough exposure to these patient presentations during TTD – creating a disconnect between anticipated clinical exposure and the expectation for residents to achieve competence in EPA 1. Methods: To overcome this gap, U of T EM faculty specifically targeted EPA 1 while designing the TTD curriculum. Kern's six-step approach to curriculum development in medical education was used. This six-step approach involves: problem identification, needs assessment, goals and objectives, education strategies, implementation and evaluation. To maximize feasibility of the new curriculum, existing sessions were mapped against EPAs and required training activities to identify synchrony where possible. Residents were scheduled on EM rotations with weekly academic days that included this novel curriculum. Curriculum, Tool or Material: Didactic lectures, procedural workshops and simulation were closely integrated in TTD to address EPA 1. Lectures introduced approaches to cardinal presentations. An interactive workshop introduced ACLS and PALS algorithms and defibrillator use. Three simulation sessions focused on ACLS, shock, airway, trauma and the altered patient. A final simulation session allowed spaced-repetition and integration of these topics. After the completion of TTD, residents participated in a six-scenario simulation OSCE directly assessing EPA 1. Conclusion: The curriculum was evaluated using a multifaceted approach including surveys, self-assessments, faculty feedback and OSCE performance. Overall, the curriculum achieved its goal in addressing EPA 1. It was well-received by faculty and residents. Residents rated the sessions highly, and self-reported improved confidence in assessing unstable patients and adhering to ACLS algorithms. The simulation OSCE demonstrated expected competency by residents in EPA 1. One limitation identified was the lack of a pediatric simulation session which has now been incorporated into the curriculum. Moving forward, this innovative curriculum will undergo continuous cycles of evaluation and improvement with a goal of applying a similar design to other stages of CBD.

MP23: Giving medical students what they deserve - a rigorous, equitable and defensible CaRMS selection process

Innovation Concept: The fairness of the Canadian Residency Matching Service (CaRMS) selection process has been called into question by rising rates of unmatched medical students and reports of bias and subjectivity. We outline how the University of Saskatchewan Royal College emergency medicine program evaluates CaRMS applications in a standardized, rigorous, equitable and defensible manner. Methods: Our CaRMS applicant evaluation methods were first utilized in the 2017 CaRMS cycle, based on published Best Practices, and have been refined yearly to ensure validity, standardization, defensibility, rigour, and to improve the speed and flow of data processing. To determine the reliability of the total application scores for each rater, single measures intraclass correlation coefficients (ICCs) were calculated using a random effects model in 2017 and 2018. Curriculum, Tool or Material: A secure, online spreadsheet was created that includes applicant names, reviewer assignments, data entry boxes, and formulas. Each file reviewer entered data in a dedicated sheet within the document. Each application was reviewed by two staff physicians and two to four residents. File reviewers used a standardized, criterion-based scoring rubric for each application component. The file score for each reviewer-applicant pair was converted into a z-score based on each reviewer's distribution of scores. Z-scores of all reviewers for a single applicant were then combined by weighted average, with the group of staff and group of residents each being weighted to represent half of the final file score. The ICC for the total raw scores improved from 0.38 (poor) in 2017 to 0.52 (moderate) in 2018. The data from each reviewer was amalgamated into a master sheet where applicants were sorted by final file score and heat-mapped to offer a visual aid regarding differences in ratings. Conclusion: Our innovation uses heat-mapped and formula-populated spreadsheets, scoring rubrics, and z-scores to normalize variation in scoring trends between reviewers. We believe this approach provides a rigorous, defensible, and reproducible process by which Canadian residency programs can appraise applicants and create a rank order list.

P125: Faculty development in the age of competency-based medical education: a national, cross-sectional needs assessment for Canadian emergency medicine faculty

Introduction: In July 2018, Emergency Medicine (EM) transitioned to the Royal College of Physicians and Surgeons of Canada's (RCPSC) Competence by Design (CBD) training framework. In anticipation of CBD implementation, we conducted a nation-wide needs assessment of EM faculty and senior residents to understand their attitudes towards CBD, workplace-based assessments (WBA) and overall educational needs. Methods: A multi-site, cross-sectional digital survey was conducted in winter 2018 with a sample of EM faculty and senior residents across RCPSC EM programs in Canada. Recruitment was via program director nomination. Survey domains included baseline perceptions about CBD, attitudes toward implementation, perceived/prompted and unperceived faculty development needs. Microsoft Excel was used to calculate descriptive statistics. This study was reviewed by the Hamilton Integrated Research Ethics Board.A multi-site, cross-sectional digital survey was conducted in winter 2018 with a sample of EM faculty and senior residents across RCPSC EM programs in Canada. Recruitment was via program director nomination. Survey domains included baseline perceptions about CBD, attitudes toward implementation, perceived/prompted and unperceived faculty development needs. Microsoft Excel was used to calculate descriptive statistics. This study was reviewed by the Hamilton Integrated Research Ethics Board. Results: Between February-April 2018, 47 participants (40 faculty, 7 residents) completed the survey (58.8% response rate). Most respondents (89.4%) thought learner feedback should be provided on each shift; 55.3% believed they provided adequate feedback. Time constraints, learner disinterest and fear of assessment repercussions were the top three barriers to providing good feedback. A majority of respondents (78.7%) thought that the ED provided above average opportunities for direct observation and 91.5% were confident of incorporating WBAs into their practice. 44.7% reported that CBD will not impact patient care; 17.0% perceived it may have a negative impact. 55.3% felt that CBD will lead to improved feedback for trainees. The top areas for faculty development were: feedback delivery, completing WBAs, resident promotion decisions, and receiving feedback on teaching. Only 25.5% were interested in learning about CBD, although the average of correct responses on the CBD knowledge test was 44.6%. Conclusion: EM is well-situated to transition to CBD given clinicians’ positive attitudes towards feedback, direct observation, WBAs, and opportunities for direct observation. Threats to CBD implementation are concerns about effects on patient care and trainee education, and skepticism regarding effects on feedback quality. Faculty development should concentrate on further developing clinical teaching and supervision skills, focusing on feedback and WBAs.

P122: Narrative assessment of emergency medicine learners: What should we keep as we move to competency-based assessment?

Introduction: For many years, Emergency Medicine (EM) educators have used narrative comments to assess their learners on each shift, either in isolation or combined with some type of Likert scale ranking. Competency based medical education (CBME), soon to be fully implemented throughout Canadian EM educational programs, encourages this type of frequent low-stakes narrative assessment. It is important to understand what information is currently garnered from existing narrative assessments in order to successfully and smoothly transition to the CBME system. The purpose of this study was to explore how one Canadian undergraduate EM program's narrative assessment comments mapped to two competency frameworks: one traditional CanMEDS-based and one competency-based, built on entrustable professional activities (EPAs). Methods: A qualitative and quantitative content analysis of 1925 retrospective, narrative assessments was conducted for the 2015/2016 and 2016/2017 academic years. The unprompted comments were mapped to the Royal College CanMEDS framework and the Association of Faculties of Medicine of Canada EPA Framework. Using an iterative coding process as per accepted qualitative methodologies, additional codes were generated to classify comments and identify themes that were not captured by either framework. Results: 93% and 85% of the unprompted narrative assessments contained comments that mapped to at least one CanMEDS role or EPA competency, respectively. The most common CanMEDS role commented upon was Medical Expert (86%), followed by Communicator, Collaborator and Scholar (all at 23%). The most common EPA competency mentioned related to history and physical findings (62%) followed by management plan (33%), and differential diagnosis (33%). However, 75% of narrative comments contained within the assessments, included ideas that did not fall into either framework but were repeated with frequency to suggest importance. The experiential characteristics of working with a learner were commented upon by 22% of preceptors. Other unmapped themes included contextual information, generalities and platitudes, and directed feedback for next steps to improve. Conclusion: While much of the currently captured data can be mapped to established frameworks, important information for both learner and assessor may be lost by limiting comments to the competencies described within a particular framework, suggesting caution when transitioning to a CBME assessment program.

An environmental scan of quality improvement and patient safety activities in emergency medicine in Canada.

We conducted an environmental scan of quality improvement and patient safety (QIPS) infrastructure and activities in academic emergency medicine (EM) programs and departments across Canada. We developed 2 electronic surveys through expert panel consensus to assess important themes identified by the CAEP QIPS Committee. "Survey 1" was sent by email to all 17 Canadian medical school affiliated EM department Chairs and Academic Hospitals department Chiefs; "Survey 2" to 12 identified QIPS leads in these hospitals. This was followed by 2 monthly email reminders to participate in the survey. 22/70 (31.4%) Department Chairs/Chiefs completed Survey 1. Most (81.8%) reported formal positions dedicated to QIPS activities within their groups, with a mixed funding model. Less than half of these positions have dedicated logistical support. 11/12 (91.7%) local QIPS leads completed Survey 2. Two-thirds (63.6%) reported explicit QIPS topics within residency curricula, but only 9.1% described QIPS training for staff physicians. Many described successful academic scholarship output, with the total number of peer-reviewed QIPS-related publications per centre ranging from 1-10 over the past 5 years. Few respondents reported access to academic supports: methodologists (27.3%), administrative personnel (27.3%), and statisticians (9.1%). This environmental scan provides a snapshot of QIPS activities in EM across academic centres in Canada. We found significant local educational and academic efforts, although there is a discrepancy between the level of formal support/infrastructure and such activities. There remains opportunity to further advance QIPS efforts on a national level, as well as advocating and supporting local QIPS activities.

An Overview of the Allopathic Match.

The number of allopathic emergency medicine (EM) programs has been progressively increasing over the years. In 2018, allopathic EM postgraduate year-1 spots, compared with 2012, increased by around 60% to reach 2278 positions. EM is considered a competitive specialty and therefore, in this article we help guide students interested in EM through the allopathic match requirements, application process, interviews, and ranking EM programs. Additionally, we tackle the combined emergency medicine residency programs, namely the combined EM-Family Medicine (FM), EM-Anesthesiology, EM-Internal Medicine (IM), EM-IM-Critical Care Medicine, and EM-Pediatrics residency programs. Finally, we explain the increased likelihood of matching with the single graduate medical education accreditation system expected to happen in the year2020.

The Diversity Snowball Effect: The Quest to Increase Diversity in Emergency Medicine: A Case Study of Highland's Emergency Medicine Residency Program

Blacks, Hispanics/Latinos, American Indians, Pacific Islanders, Alaska Natives, and Native Hawaiians make up 33% of the US population. These same groups are underrepresented in medicine. In 2013, the physician workforce was 4.1% black, 4.4% Hispanic/Latino, 0.4% American Indian or Alaska Native, 11.7% Asian, and 48.9% white. Only 9.9% of emergency physicians identify as underrepresented minority (4.5% black, 4.8% Hispanic/Latino, and 0.6% American Indian/Alaska Native). Efforts to increase the number of underrepresented minority physicians are important because previous studies show improved outcomes when the patient and physician share the same racial/ethnic background. Starting in 2006, the faculty at the Highland EM Residency Program in Oakland, CA, began a diversification initiative to increase the number of underrepresented minority residents. The goal was to closely mirror the US population and match 30% underrepresented minorities with each incoming class. After the initiative, there was a 2-fold increase in the number of underrepresented minority residents (from 12% to 27%). This article is a review of the strategies used to diversify the Highland EM Residency Program. Most components can be applied across emergency medicine programs to increase the number of underrepresented minority residents and potentially improve health outcomes for diverse populations.