Residency-trained Physicians Research Articles

Comparison of artificial intelligence versus real-time physician assessment of pulmonary edema with lung ultrasound

BackgroundLung ultrasound can evaluate for pulmonary edema, but data suggest moderate inter-rater reliability among users. Artificial intelligence (AI) has been proposed as a model to increase the accuracy of B line interpretation. Early data suggest a benefit among more novice users, but data are limited among average residency-trained physicians. The objective of this study was to compare the accuracy of AI versus real-time physician assessment for B lines. MethodsThis was a prospective, observational study of adult Emergency Department patients presenting with suspected pulmonary edema. We excluded patients with active COVID-19 or interstitial lung disease. A physician performed thoracic ultrasound using the 12-zone technique. The physician recorded a video clip in each zone and provided an interpretation of positive (≥3 B lines or a wide, dense B line) or negative (<3 B lines and the absence of a wide, dense B line) for pulmonary edema based upon the real-time assessment. A research assistant then utilized the AI program to analyze the same saved clip to determine if it was positive versus negative for pulmonary edema. The physician sonographer was blinded to this assessment. The video clips were then reviewed independently by two expert physician sonographers (ultrasound leaders with >10,000 prior ultrasound image reviews) who were blinded to the AI and initial determinations. The experts reviewed all discordant values and reached consensus on whether the field (i.e., the area of lung between two adjacent ribs) was positive or negative using the same criteria as defined above, which served as the gold standard. Results71 patients were included in the study (56.3% female; mean BMI: 33.4 [95% CI 30.6–36.2]), with 88.3% (752/852) of lung fields being of adequate quality for assessment. Overall, 36.1% of lung fields were positive for pulmonary edema. The physician was 96.7% (95% CI 93.8%–98.5%) sensitive and 79.1% (95% CI 75.1%–82.6%) specific. The AI software was 95.6% (95% CI 92.4%–97.7%) sensitive and 64.1% (95% CI 59.8%–68.5%) specific. ConclusionBoth the physician and AI software were highly sensitive, though the physician was more specific. Future research should identify which factors are associated with increased diagnostic accuracy.

Emergency Medicine Around the World: Analysis of the 2019 American College of Emergency Physicians International Ambassador Country Reports.

ObjectiveThe specialty of emergency medicine and recognition of the need for emergency care continue to grow globally. The specialty and emergency care systems vary according to context. This study characterizes the specialty of emergency medicine around the world, trends according to region and income level, and challenges for the specialty.MethodsWe distributed a 56‐question electronic survey to all members of the American College of Emergency Physicians International Ambassador Program between March 2019 and January 2020. The Ambassador Program leadership designed the survey covering specialty recognition, workforce, system components, and emergency medicine training. We analyzed results by country and in aggregate using SAS software (SAS Institute Inc). We tested the associations between World Bank income group and number of emergency medicine residency‐trained physicians (RTPs) and emergency medicine specialty recognition using non‐parametric Fisher's exact testing. We performed inductive coding of qualitative data for themes.ResultsSixty‐three out of 78 countries’ teams (80%) responded to the survey. Response countries represented roughly 67% of the world's population and included countries in all World Bank income groups. Fifty‐four countries (86%) recognized emergency medicine as a specialty. Ten (16%) had no emergency medicine residency programs, and 19 (30%) had only one. Eight (11%) reported having no emergency medicine RTPs and 30 (48%) had <100. Fifty‐seven (90%) had an emergency medical services (EMS) system, and 52 (83%) had an emergency access number. Higher country income was associated with a higher number of emergency medicine RTPs per capita (P = 0.02). Only 6 countries (8%) had >5 emergency medicine RTPs per 100,000 population, all high income. All 5 low‐income countries in the sample had <2 emergency medicine RTPs per 100,000 population. Challenges in emergency medicine development included lack of resources (38%), burnout and poor working conditions (31%), and low salaries (23%).ConclusionsMost surveyed countries recognized emergency medicine as a specialty. However, numbers of emergency medicine RTPs were small, particularly in lower income countries. Most surveyed countries reported an EMS system and emergency access number. Lack of resources, burnout, and poor pay were major threats to emergency medicine growth.

Emergency Medicine Challenges in Ecuador.

IntroductionEmergency medicine (EM) was recognized as a specialty in Ecuador in 1993. Currently, there are two four-year EM residency programs and an estimated 300 residency-trained emergency physicians countrywide. This study describes the current challenges in EM in Ecuador.MethodsWe conducted 25 semi-structured, in-person interviews with residency-trained emergency physicians, general practitioners, public health specialists, prehospital personnel, and physicians from other specialties. The interviewer asked about challenges in the areas of emergency care, working conditions of emergency physicians, EM residency education, EM leadership, and prehospital care. We analyzed data for challenges and registered the number of interviewees who mentioned each challenge.ResultsInterviewees worked in the three largest cities in the country: Quito (60%); Guayaquil (20%); and Cuenca (20%). Interviewees included 16 (64%) residency-trained emergency physicians; six (24%) residency-trained physicians from other specialties working in or closely associated with the emergency department (ED); one (4%) general practitioner working in the ED; one (4%) specialist in disasters; and one (4%) paramedic. Shortage of medical supplies, need for better medico-legal protection, lack of EM residencies outside of Quito, and desire for more bedside teaching were the challenges mentioned with the highest frequency (each 44%). The next most frequently mentioned challenges (each 38%) were the need for better access to ultrasound equipment and the low presence of EM outside the capital city. Other challenges mentioned included the low demand for emergency physicians in private institutions, the lack of differential pay for night and weekends, need for more training in administration and leadership, need for a more effective EM national society, and lack of resources and experience in EM research.ConclusionEmergency medicine has a three-decade history in Ecuador, reaching important milestones such as the establishment of two EM residencies and a national EM society. Challenges remain in medical care, working conditions, residency education, leadership, and prehospital care. Stronger collaboration and advocacy among emergency physicians can help strengthen the specialty and improve emergency care.

Physician Age and Performance on the American Board of Emergency Medicine ConCert Examination.

This study was undertaken to expand on results from a 2014 study on the association between physician age and performance on the American Board of Emergency Medicine (ABEM) ConCert examination. This was a retrospective, longitudinal growth study comparing performance on the ConCert examination and physicians' ages at the time of examination. All examination attempts from 1990 to 2016 made by residency-trained physicians were eligible for inclusion. Multilevel growth models were constructed to examine the relationship between age at time of examination and performance, controlling for physician characteristics. The study group included 15,533 examination attempts by 12,786 physicians. The mean (±SD) age of the physicians across all examination administrations was 45.02 (±5.18) years (range= 35 to 72 years). The mean (±SD) ConCert examination score across all administrations was 85.39 (±5.71; range= 51 to 100). Among first-time ConCert examination takers, older age was associated with lower examination scores (r=-0.25, p<0.0001). Across all examination attempts, age was negatively correlated to examination scores (r=-0.24; p<0.0001). After physician characteristics were controlled for, there was an association between advancing age and declining performance on the ABEM ConCert examination. This information may be important to the individual physician to develop targeted competency assessment and professional development.

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A comparison of emergency medicine resident clinical experience in a rural versus urban emergency department

Strategies for increasing the numbers of American Board of Emergency Medicine certified/emergency medicine (EM) residency trained physicians practicing in rural emergency departments (EDs) include providing rural EM experiences during residency training. However, no studies to date describe the clinical work of EM residents rotating in a rural ED. The objective of the study was to compare the clinical experience of EM residents participating in a rural ED rotation with that on an urban university-based ED rotation. Second-year EM residents completing both urban and rural clinical ED rotations self-reported the number of patients evaluated, number of patients admitted and admitting bed type, and the number and type of procedures performed over a 6 month period. Total admission rates, telemetry admission rates, and intensive care unit (ICU) admission rates were calculated and compared by z-test for two proportions. Total numbers for central venous access, conscious sedation, dislocation or fracture relocation/reduction endotracheal intubation, laceration repair, lumbar puncture, tube thoracostomy adult medical resuscitation, adult trauma resuscitation, pediatric medical resuscitation, pediatric trauma resuscitation, and the total number of ED hours completed at each clinical site were collected and procedure/resuscitation numbers calculated per 100 resident-hours in the ED. Five of six residents completed the patient data forms requested. Patients evaluated per hour in the rural versus urban EDs were 1.22 and 1.21, respectively. Rural versus urban ED total admission rates were 21.74% (95% CI, 28.19.01-24.47) versus 33.35% (31.50-35.20), telemetry admission rates were 3.40% (2.28-4.52) versus 14.24% (12.87-15.61), and ICU admission rates were 0.9% (0.31-1.49) versus 4.38% (3.58-5.18), with the differences in all admission rates determined to be statistically significant. Rural versus urban procedures/100 resident-hours in the ED were 0 versus 0.6 for central venous access (p = 0.087), 0.8 versus 0.3 for conscious sedation (p = 0.170), 1.3 versus 0.2 for dislocation or fracture relocation/reduction (p = 0.001), 0 versus 0.9 for endotracheal intubation (p = 0.026), 6.1 versus 2.7 for laceration repair (p < 0.001), 1.0 versus 1.0 for lumbar puncture (p = 0.845), 0.4 versus 0.2 for tube thoracostomy (p = 0.720), 2.4 versus 3.6 for adult medical resuscitation (p = 0.135), 0.7 versus 2.1 for adult trauma resuscitation (p = 0.023), 0.6 versus 0.3 for pediatric medical resuscitation (p = 0.642), and 0.8 versus 0.2 for pediatric trauma resuscitation (p = 0.034). The higher frequency of endotracheal intubations and adult trauma resuscitations per 100 resident-hours in the urban versus rural EDs was statistically significant by z-test, while laceration repair, dislocation/fracture relocation/reduction, and pediatric trauma resuscitations occurred more frequently in the rural ED by statistically significant margins. No other procedure or resuscitation type differed significantly. A rural ED rotation provides an active clinical experience, with patients per hour and most procedure frequencies being similar to those at urban sites, but with lower patient acuity as determined by admission rates.

Bedside Ultrasound for the Detection of Soft Tissue Foreign Bodies: A Cadaveric Study

The objective of this study was to evaluate the sensitivity and specificity of bedside ultrasound, as performed by emergency physicians with typical equipment, in detecting small, soft tissue foreign bodies, using a cadaveric model. This was a prospective study, using 6 unembalmed human cadavers and 6 ultrasound-credentialed, emergency medicine residency-trained physicians as sonographers. Incisions were made in 150 total sites of the extremities and each site was randomly assigned one of five groups: wood, metal, plastic, glass, or no foreign body. All foreign bodies were 2.5 mm 3 in total volume or less, no longer than 5 mm in any dimension, and inserted to a depth of up to 3 cm. Ultrasound was performed with a SonoSite TITAN ® (SonoSite, Inc., Bothell, WA) ultrasound system using a L38/10-5 broadband linear array transducer. Sonographers were blinded to the number, type, and location of foreign bodies. A total of 900 ultrasound examinations were recorded. Overall sensitivity of ultrasound for foreign body detection was 52.6% (95% confidence interval [CI] 48.9%–56.2%), and overall specificity was 47.2% (95% CI 39.9%–54.5%). Positive predictive value was 79.9% (95% CI 76.3%–83.5%), and negative predictive value was 20.0% (95% CI 16.2%–23.7%). Sensitivity for individual sonographers ranged from 40.8% to 72.3% (average 52.6% ± 13.3%), and specificity ranged from 30% to 66.7% (average 47.2% ± 15.1%). Inter-observer reliability was poor. In our model, bedside ultrasound performed by emergency physicians was neither sensitive nor specific for the presence of small soft tissue foreign bodies.

Survey of U.S. Army Commanders' Experiences with Brigade/Battalion Surgeons at Fort Hood, Texas

This anonymous survey sent to every battalion and brigade commander at Fort Hood, Texas assessed the new concept of residency-trained operational physicians that had completed military unique curriculum series training. Commanders provided anonymous professional information about themselves and their assigned physicians and evaluated their physicians in 22 areas of medical and military competence using a linear scoring method from 2 (indicating poor) to 6 (indicating outstanding). Main effects and interaction effects were analyzed using multiple analysis of variance. The commanders' overall confidence in their physicians was 5.4, suggesting general satisfaction. Prior-service physicians were rated higher on several factors if the commander had combat experience. Non-prior-service physicians were rated the same on nearly all variables regardless of the commander's experience. Commanders with combat experience rated their assigned physicians significantly higher than did commanders without combat experience. Despite high ratings, several candid remarks suggest there is still room for improvement.

Interesting Cases

The objective of this study was to evaluate the sensitivity and specificity of bedside ultrasound, as performed by emergency physicians with typical equipment, in detecting small, soft tissue foreign bodies, using a cadaveric model. This was a prospective study, using 6 unembalmed human cadavers and 6 ultrasound-credentialed, emergency medicine residency-trained physicians as sonographers. Incisions were made in 150 total sites of the extremities and each site was randomly assigned one of five groups: wood, metal, plastic, glass, or no foreign body. All foreign bodies were 2.5 mm3 in total volume or less, no longer than 5 mm in any dimension, and inserted to a depth of up to 3 cm. Ultrasound was performed with a SonoSite TITAN® (SonoSite, Inc., Bothell, WA) ultrasound system using a L38/10-5 broadband linear array transducer. Sonographers were blinded to the number, type, and location of foreign bodies. A total of 900 ultrasound examinations were recorded. Overall sensitivity of ultrasound for foreign body detection was 52.6% (95% confidence interval [CI] 48.9%–56.2%), and overall specificity was 47.2% (95% CI 39.9%–54.5%). Positive predictive value was 79.9% (95% CI 76.3%–83.5%), and negative predictive value was 20.0% (95% CI 16.2%–23.7%). Sensitivity for individual sonographers ranged from 40.8% to 72.3% (average 52.6% ± 13.3%), and specificity ranged from 30% to 66.7% (average 47.2% ± 15.1%). Inter-observer reliability was poor. In our model, bedside ultrasound performed by emergency physicians was neither sensitive nor specific for the presence of small soft tissue foreign bodies.

Malpractice occurrence in Emergency Medicine: Does residency training make a difference?

We evaluated the effects of Emergency Medicine (EM) residency training, EM board certification, and physician experience on the occurrence of malpractice claims and indemnity payments. This was a retrospective review of closed malpractice claims from a single insurer. Outcome measures included the occurrence of claims resulting in indemnity, indemnity amounts, and defense costs. Differences in the outcome measures were compared based on: EM residency training, EM board certification, EM residency training versus other residency training, and physician experience using both univariate and multivariate analyses. There were 428 closed EM claims with indemnity paid in 81 (18.9%). Indemnity was paid in 22.4% of closed claims against non-EM residency-trained physicians, and in only 13.3% against EM residency-trained physicians ( p = 0.04). The total indemnity was $6,214,475. Non-EM trained physicians accounted for $4,440,951 (71.5%), EM residency-trained physicians accounted for $1,773,524 (28.5%). The average indemnity was $76,721 and the average defense cost was $17,775. There were no significant differences in the mean indemnity paid per closed claim or the mean cost to defend a closed claim when comparing EM-trained and non-EM residency-trained physicians. The total cost (indemnity + defense costs) per physician-year of malpractice coverage was $4,905 for non-EM residency-trained physicians and $2,212 for EM residency-trained physicians. EM residency-trained physicians account for significantly less malpractice indemnity than non-EM residency-trained physicians. This difference is not due to differences in the average indemnity but is due to significantly fewer closed claims against EM residency-trained physicians with indemnity paid. This results in a cost per physician-year of malpractice coverage for non-EM residency-trained physicians that is over twice that of EM residency-trained physicians.

A characterization of the imminent leadership transition in academic family medicine

Of the 106 identified chairmen of academic departments, divisions, or sections of family medicine in the United States in 1990, 97 (92%) responded to a survey designed to characterize the current chairmen of family medicine and estimate requirements for future chairmen. Even though 43% had occupied the chair for less than five years, over half, not limited to older chairmen, intended to leave within five years. Reasons for leaving varied, including being required to leave, career choice, personal reasons, and especially dissatisfaction with the job. Only half of current chairmen identified one or more qualified applicants for chairmanship within their own departments. The formal training and experience of these potential chairmen strongly resembled the training and experience of current chairmen, especially the fact that they had little training or experience in research. In the 1990s, the demand for academic chairmen of family medicine is likely to be large, the competition for capable candidates keen, and the challenges great for new chairmen, who will probably be young, residency-trained family physicians with relatively limited academic experience.

Orthopedic Trauma: A Family Practice Perspective

It is well documented that residency-trained family physicians can effectively manage the majority of nonsurgical acute orthopedic injuries with a relatively small rate of consultation. The frequency of both fracture location and orthopedic review in our series are remarkably similar to the study from NRMC Charleston reported in 1981. Our program, however, is unique because of the comprehensive management, 3-year continuous training, and multidimensional educational experience. A critical element to the program is the excellent working relationship shared by the family practice and orthopedic departments. A clinic similar to the Davis Grant USAF Medical Center cast clinic could be implemented easily and would better train the family practice resident to manage nonsurgical orthopedic trauma.

Effect of nutrition education on nutrition counseling practices of family physicians.

The effects of completing a comprehensive nutrition curriculum on the nutrition counseling practices of family physicians trained at the University of Manitoba were investigated by sending a questionnaire to a group of these physicians who had completed the nutrition curriculum and a group that had not. The 48 responding family practice residency-trained physicians who had completed the nutrition curriculum, and the 41 responding hospital-trained physicians who had not, reported counseling practices that were not significantly different (p greater than .05). Implications and recommendations for future teaching of nutrition counseling skills to physicians during residency training are presented.

Practice characteristics and quality of primary medical care: the doctor-patient relationship.

Physician and practice characterisitics were reviewed in relation to the quality of the doctor-patient relationship in primary medical care. This relationship was defined in terms of communication between physicians and patients, patient satisfaction with care, and physician awareness of patient concerns. The study subjects were mothers of infants and pregnant women, identified from the offices of a random sample of primary care physicians is a single community. The patients of 49 physicians, 363 pregnant women and the mothers of 523 infants were the subjects of the study. When controlled for patient characteristics, communication was better for pediatricians with mothers of infants and for obstetricians with pregnant women as compared with other physicians. Mothers of infants were more highly satisfied with care provided by residency-trained physicians; pregnant women were more satisfied with non-Board certified physicians. Physician awareness of patient concerns presented a mixed pattern of associations with several physicians and practice characteristics. These findings suggest that physician credentials are not consistently associated with the three identified dimensions of the doctor-patient relationship.

Army medicine in Europe.

<h3>To the Editor:</h3> —Having spent the month of June (1952) making a consultant and teaching tour of the U. S. Army hospitals in Germany and Austria, it occurred to me that many of our profession would be interested in up-to-date observations of Army medicine in these countries. In contrast with my experiences in a similar tour in 1948, when practically all hospitals, with the exception of the two general hospitals, had as chiefs of medical service physicians who had just completed their internship, now, almost without exception, each physician on each medical service has had residency training. The incidence of physicians who have had only internship training will increase as the full effect of the policy of calling up physicians on completion of their internship is manifest. It is assumed that a sufficient number will be deferred for residency training to maintain a proper ratio of intern-trained and residency-trained physicians