Top 10 tips to building a productive academic team

I have been meaning to share this list of great tips about building a productive academic team. Major projects often require an interdisciplinary team of experts who are equally motivated towards a shared goal. I was recently at the 2012 Society of Academic Emergency Medicine where Dr. William McGaghie gave an inspiring CDEM keynote speech. He has been on a myriad of successful academic teams and he shared with us his top 10 list of pearls for team-building.

William C. McGaghie, PhD

• Jacob R. Suker, MD, Professor of Medical Education
• Professor of Preventive Medicine
• Director of Evaluation, Northwestern University Clinical and Translational Sciences (NUCATS) Institute
• Northwestern University Feinberg School of Medicine Center for Education in Medicine

I am in the process of building a big academic team myself, comprising of rheumatologists, software engineers, instructional design experts, and an education research expert. This list came in quite handy for me and so I thought I'd share.

The team should have:

1. Shared goals—common mission & vision
2. Functional diversity (everyone should have different defined roles)
3. Clear leadership—may change or rotate
4. Shared mental models & language
5. High standards, recognition, & credit
6. Sustained hard work / commitment
7. Physical proximity
8. Minimize status differences within the team
9. Maximize status of the team
10. Shared activities that breed trust

While these tips may seem obvious, they are a worthwhile reminder nonetheless. Dr. McGaghie shared examples where different members took the lead on different manuscripts within the overarching project and that everyone's opinions were valued. I found it interesting that he felt that physical proximity contributed to the success of his projects. In-person meetings and check-ins seem to have provided added value.

KidsCareEverywhere-Vietnam study findings: SAEM 2012 meeting

I recently had the pleasure of presenting our KidsCareEverywhere-Vietnam team's study findings at the national SAEM meeting in Chicago.

Bottom line: 
Despite knowing English as a second language, Vietnamese physicians were able to easily navigate an English-based, clinical decision support software (PEMSoft) after only a brief 80-minute training session, conducted by non-physicians. Their post-test exam scores improved by 84%!

SAEM meeting: May 9-12, 2012 in Chicago

What are you doing this week? Are you at the annual SAEM meeting in Chicago? Stop by and say hi. There is an impressive list of abstract presentations for the meeting. I'll be giving an oral presentation on research data from KidCareEverywhere:

"An English-based pediatric emergency medicine software improves physician test performance: A multicenter study in Vietnam"

All I get is 5 minutes. By the time I read the title, I'll only have 4 minutes left!

Article review: New assessment method for medical students - A Script Concordance Test

What different ways can we assess learners?

This fascinating study assesses a new tool - Script Concordance Test (SCT).

Assessing clinical reasoning skills in scenarios of uncertainty: Convergent validity for a Script Concordance Test in an Emergency Medicine clerkship and residency

What are Scripts?

Scripts are organized networks of knowledge. Integrating them improves decision making. Using scripts, experts see associations while novices struggle with causality. In ambiguous cases, experts process multiple scripts with influx of new information.

What is the format of a Script Concordance Test?

The learners are presented with a short clinical vignette with a series of proposed diagnoses and/or plans. The learners are then presented one new piece of information and asked what effect this information has on the proposed diagnoses and/or plans. They score their decisions on a Likert scale, ranging from -2 to +2.

What did this paper study?

An observational study comparing the scores of 4th year med students (n=314) , residents (n=40) and faculty (n=12) on a SCT with scenarios in Emergency Medicine. The student score was compared to USMLE Step 2 score, and resident score with their ABEM in-training exam score.

What were the results?

The SCT scores were able to differentiate students from residents and residents from faculty. 

• Students vs residents: 60% +/- 6.2 vs 70% +/- 5.4
• Residents vs faculty: 70% +/- 5.4 vs 79% +/- 2.9

There was a significant correlation between resident score and ABEM exam score and a modest correlation between student score and USMLE Step 2 score.

What were the limitations?

It is a single centre study. The internal reliability of the assessment tool was suboptimal.

What were the conclusions?

The SCT may be useful in assessing clinical reasoning in uncertain scenarios.

What do I think?

I enjoy the examples given in the paper. While it is different and likely will take some getting used to, it could be a useful assessment tool.

References

Humbert AJ, Besinger B, Miech EJ. Assessing clinical reasoning skills in scenarios of uncertainty: convergent validity for a Script Concordance Test in an emergency medicine clerkship and residency. Acad Emerg Med. 2011;18(6):627-34. .

Article review: Evaluating your written evaluation of a learner

As a new faculty, one of the first challenges that I encountered was completing evaluation forms for medical students and residents. In our department, a Daily Evaluation Card (DEC) is to be completed at the end of every shift for each learner. These DEC’s are then collated by the program directors to yield a summative final rotation evaluation.

What I wondered was: how can I best use these DEC's to help learners progress as medical professionals and at the same time provide critical information for the PD’s?

Fortunately, I stumbled upon a 2008 Medical Education paper called “Assessing the quality of supervisors' completed clinical evaluation reports” by Dr. Nancy Dudek (University of Ottawa).  This article was what I was looking for. Although this article was intended to evaluate the quality of the summative evaluation, the principles remain applicable to the DEC's.

The article is summarized below:

• End-of-rotation evaluations usually consist of a checklist/rating scale and written comments. These forms have questionable reliability and validity.
• End-of-rotation evaluations remain a valuable resource when trying to assess what a trainees "actually do" versus what they "can do" (eg. on an exam).
• The study attempted to determine the features of a high-quality evaluation and to develop an instrument to assess its quality.

Methodology:

Using brainstorming and a modified Delphi consensus technique, a focus group developed a Completed Clinical Evaluation Report Rating (CCERR) form. This form was then tested nationally and revised to yield a tool which evaluated 9-items each on a 5-point scale. This CCERR tool was found to be a reliable and valid means to differentiate superior from average from poor end-of-rotation evaluations.    

The 9-item CCERR checklist:

How would your own Daily Evaluation Card evaluations fare? 

Use a 5-point scale (1 = not at all, 3 = acceptable, 5 = exemplary).

1. Checklist/ numeric ratings show sufficient variability to allow identification of relative strengths and weaknesses of the trainee.
2. Comments are balanced providing both strengths and areas for improvement.
3. The trainee’s response to feedback and/or remediation during the rotation is described in the comments.
4. Comments justify the ratings provided.
5. Clearly explained examples of strengths using specific descriptions (not generalizations) are provided in the comments.
6. Clearly explained examples of weaknesses using specific descriptions (not generalizations) are provided in the comments.
7. Concrete recommendations for the trainee to attain a higher level of performance are provided.
8. Comments are provided in a supportive manner.
9. Overall, this end-of-rotation evaluation provides enough detail for an independent reviewer to clearly understand the trainee’s performance on the rotation.

Reference

Dudek NL, Marks MB, Wood TJ, Lee AC. Assessing the quality of supervisors' completed clinical evaluation reports. Med Educ. 2008 Aug;42(8):816-22. 

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Trick of the Trade: Synovial lactate in septic arthritis

A 55 year old woman presents with rheumatoid arthritis presents with monoarticular joint pain in her left knee for the past 3 days. She has a low-grade fever of 100.2 F and a significantly warm and tender knee. "It feels different than my RA flare."

Does this patient have a septic joint?

The difficulty in diagnosing this elusive disease is that the history, physical, and serum tests are typically unhelpful in ruling in or out the disease. See my previous Paucis Verbis card covering the 2007 JAMA review on Septic Arthritis.

Interpretation of the synovial fluid is also challenging. Generally a synovial WBC count <25K suggests a non-infectious process and a WBC count >100K suggests an infectious process.

What about everything in between 25K and 100K?

Trick of the Trade:
Check if the synovial lactate level is > 10 mmol/L.

A level >10 mmol/L is highly suggestive of septic arthritis. The calculated positive likelihood ratio (LR) from multiple studies was at least 10. The negative LR ranged from  0 to 0.45.

Although the quoted studies measured lactate using liquid chromatography, presumably our point-of-care lactate levels are equivalent, based on various sepsis studies.

How do you use the LR statistic? I'm no statistician, and so I love the Bayes nomogram. This requires me to have a pretest probability for the disease. In this case, let's say that I am moderately suspicious of a septic joint given the patient's history of rheumatoid arthritis (a known risk factor), significant joint pain, and low grade fever. I'm going to say that my pretest probability is 25% (see left column of numbers).

The synovial lactate level returns at 12 mmol/L (see middle column of numbers), which gives the patient a positive LR of at least 10.

This means that my post-test probability for a septic joint jumps way up to 80%, which practically rules-in my patient for septic joint.

Reference
Carpenter CR, Schuur JD, Everett WW, Pines JM. Evidence-based Diagnostics: Adult Septic Arthritis. Acad Emerg Med. 2011;18(8), 781-96. PMID: 21843213
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Article Review: Performing a database search

At the end of each Academic Medicine journal issue, there is a great "last page" one-page teaching point in medical education research. There's no earth-shattering news, but they are great reviews of key elements in education research.

The most recent issue reviews the process of performing an effective database search in medical education research. It was authored by my friend Lauren, who is a medical education librarian at Stanford and a co-author with me on an annual series "Critical Appraisal in Emergency Medicine Education Research".

Steps for an effective search methodology:

1. Choose a database: Did you know that there's more than just Medline?

• Google Scholar: Diverse disciplines; open access
• ERIC (Education Research Information Center): Focuses only on education literature; open access
• CINAHL (Cumulative Index to Nursing and Allied Health Literature): Nursing and allied health literature; subscription needed
• Scopus: Includes broad literature from scientific, technical, medical, and social sciences; subscription needed

2. Select search terms

• Use controlled vocabulary to perform a more complete search. Pubmed uses Medical Subject Headings (MeSH).
• Don't forget to use truncation. This allows you to avoid missing any slight variation in your search term. So for Pubmed, typing educat* captures educator, educators, education, educate, and educatify (if that word actually existed!) for instance. 

3. Use Boolean operators

• Use OR and AND connectors to broaden or narrow your searches, respectively.

4. Limit results

• Apply limits one at a time to your search to narrow your search pool in a stepwise fashion.
• Common limits applied: English language, date ranges

5. Explain the search process in the methodology section of any report: Your methodology should include all the following:

• Database(s) searched
• Search terms (indicate if controlled vocabular used)
• Boolean operators
• Limits applied
• Date of search

Reference
Maggio LA, Tannery NH, Kanter SL. AM Last Page: How to Perform an Effective Database Search. Academic medicine. 2011; 86(8) PMID: 21795907
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SAEM 2012 Consensus Conference: Education Research in EM

It has just been announced that the upcoming 2012 SAEM annual meeting will feature a full-day Consensus Conference on Education Research in Emergency Medicine. In the past, Consensus Conferences have focused on such areas as "Interventions to Assure Quality in the Crowded Emergency Department" and "The Science of Simulation in Healthcare: Defining and Developing Clinical Expertise".

There's introductory information on the SAEM Facebook page. The format is a bit cluttered, so I am reposting here below:

 2012 Academic Emergency Medicine Consensus Conference

“Education Research in Emergency Medicine:

Opportunities, Challenges and Strategies for Success”

The 2012 Academic Emergency Medicine Consensus Conference, “Education Research in Emergency Medicine: Opportunities, Challenges and Strategies for Success” will be held on May 9, 2012, immediately preceding the SAEM Annual Meeting in Chicago, Illinois.  Original papers on the conference topic, if accepted, will be published together with the conference proceedings in the December 2012 issue of Academic Emergency Medicine.

A divide has traditionally existed in academic medicine between the educator and the researcher.  The goal of this conference is to bridge this gap, by exploring the principles that guide these two allied disciplines to create a unified focus on education research science that will benefit our teachers, our learners and ultimately our patients.

Emergency medicine (EM) educators have long perceived the need for better research to guide the frequent challenges encountered in the academic environment.   These include identifying best practice teaching methods, validating assessment tools, evaluating competency, and preventing cognitive errors.  Efforts to address these challenges have begun; however the historical use of suboptimal study designs, subjective outcomes, small samples sizes, and lack of expertise in methods useful in other domains can limit the success of education research studies. A coordinated agenda for EM education research is needed to address these topics and streamline our research efforts.

The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project now mandates that training programs demonstrate the effectiveness of educational interventions and show evidence of trainee aptitude and achievement in the core competencies.   The American Board of Emergency Medicine (ABEM) now requires its diplomats to provide evidence of Assessment of Practice Performance in order to receive continuous certification.  These and other requirements highlight the current paucity of available evidence to inform our instruction and evaluation of emergency physicians, and call for our field to develop high-quality education research.

A systematic approach to education research in EM is essential for the continued improvement of clinical emergency care, even for providers beyond residency training.    In the decade since the Institute of Medicine's 2001 "Crossing the Quality Chasm" report identified the failure of health care environments to consistently deliver evidence-based care, the increased emphasis on translational research and patient safety has identified even broader needs for education-based research.  Without well-designed studies to investigate the most effective methods to teach and evaluate emergency physicians, scientific discoveries cannot be effectively disseminated to physicians in training or in practice, nor the benefits fully realized by our patients.

This Consensus Conference on Education Research in Emergency Medicine proposes to build a solid foundation upon which EM education researchers can build interdisciplinary scholarship, networks of expertise, discussion forums, multicenter collaborations, evidence-based publications and improved learner education.  Such efforts will enable us to make significant contributions to the state of knowledge in medical education and, ultimately, to optimize patient care.

Consensus Conference Goals:

• Provide an overview of the current state of education research in EM 
• Identify and examine the barriers that educators face in conducting well-powered, rigorous education research, and develop recommendations for overcoming these barriers
• Define most appropriate and effective methods for conducting education research studies
• Identify priority agenda areas within specific education research domains, such as:
• Establishing the effectiveness of clinical and didactic curricula in educating EM trainees in each of the six ACGME core competencies
• Evaluating performance of learners across the continuum of medical education, from medical student to practicing emergency physician
• Validating educational assessment tools
• Teaching and evaluating non-cognitive ACGME core competencies, such as “Professionalism” and “Interpersonal and Communication Skills”
• Measuring the impact of educational interventions to improve patient safety
• Research designs conducive to studying education outcomes
• Develop a framework to increase collaboration, access to research support and potential funding sources and promote faculty development in education research

Original contributions describing relevant research or concepts on this topic will be considered for publication in the December 2012 issue of Academic Emergency Medicine if received by Monday, March 12, 2012.  All submissions will undergo peer review and publication cannot be guaranteed.  For queries, please contact Nicole DeIorio, MD (deiorion@ohsu.edu), Joseph LaMantia, MD (JLaManti@nshs.edu), or Lalena Yarris, MD (yarrisl@ohsu.edu), Consensus Conference Co-chairs.  Information and updates will be regularly posted in Academic Emergency Medicine, the SAEM Newsletter, and the journal and SAEM websites.

New website for medical education researchers

There is a great new website "Medical Education Subject Guide", hosted by UCSF's own Josephine Tan, tailored to medical education research and academic scholarship. I've been a long-time admirer of Josephine's work as an Education and Information Consultant in Clinical Sciences for the UCSF Library.

This compiles and lists helpful resources, which include books, journals, databases, multimedia resources, organizations, literature search tips, and blogs. The site also links to her two blogs:

Medical Education Literature Searching

• Literature searching tips and educational insights

In Plain Sight

• This blog provides information searching and citation management tips,  as well as educational insights to enhance the faculty, researcher, clinician, and student information seeking, management, presentation, and publication experience.

Wish I had these resources when I became interested in medical education and education research...

Article review: Professionalism in the ED through the eyes of medical students

Teaching professionalism in a formal curriculum is so much different than demonstrating professionalism in the Emergency Department. So much of what students and residents learn about professionalism are from observed behaviors of the attending physicians -- that is, the hidden curriculum.

In a qualitative study assessing medical student reflection essays during an EM clerkship, the authors (my friends Dr. Sally Santen and Dr. Robin Hemphill) found some startling results. The instructions to the medical students were to “think about an aspect of professionalism that has troubled you this month. Write a minimum of one half-page reflection describing what was concerning and how you might handle it.”

Results:

• 61 of 150 reflection essays discussed professionalism themes.
• Using a grounded theory approach, the authors first looked at the data and then created categorical themes. 

Analytic Domains
1. Demonstration of positive professional behavior

• Demonstration of compassion and empathy
• Tension between respecting diversity and respecting other core values
• Balance between patient-centered care and effective care 
• Commitment to ethical principles

2. Observation of unprofessional behavior 

• Lack of compassion 
• Not telling the truth 
• Lack of teamwork 
• Inappropriate medical care

3. Personal improvement and learning

• Whether to speak up because they are subordinate in a hierarchy 
• Plans for their own future personal professional behavior through reflection on observed professional and unprofessional behavior and their own behavior

The take-home point is that unprofessional behavior definitely occurs in the ED to varying degrees, and medical students are astute at identifying these. There were examples of lack of compassion, struggles in prescribing opiates to apparently drug-seeking patients, and not telling patients the truth.

As residents and faculty, we must maintain an open-mind and set high standards for professionalism. Even if you aren't being called out on it, learners are noticing. They just might not be vocalizing their concerns because of their role as "subordinates" in a hierarchy who depend on evaluations to secure a good grade on their rotation.

Especially with young, impressionable new medical students and interns in the ED soon to start in the new academic year, remember to lead by example.

Reference 
Santen SA, Hemphill RR. A Window on Professionalism in the Emergency Department Through Medical Student Narratives. Annals of emergency medicine. 2011 - in early press. PMID: 21624702
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Article review: Improving case presentations with theater training

"To be or not to be?"

What could be more strange on a medical school curriculum than a theater training course? The authors of this study in Medical Humanities innovatively designed a 1-week elective course to help medical students at Mayo Medical School to improve their case presentation skills in partnership with the Guthrie Theater.


In this pilot course, seven medical students (six 1st year students, one 4th year student) participated. The learning objectives were:

• Hear stories: those told by patients, colleagues and in written narratives
• Identify the elements of a narrative, and examine stories for narrative structure 
• Share stories: through case presentations, body movement, storytelling and acting 
• Present a patient’s story with elements of traditional medical presentation and narrative

Students were evaluated for the following competencies:

• The cognitive capacity and flexibility needed to evaluate and acquire reliable clinical information. 
• The ability to actively and generously observe and listen to another. 
• An understanding of the components of narrative leading to effective story construction. 
• A performance sensibility that ensures the delivery of a good story, otherwise known as stage presence. 
• The finesse to communicate empathically with a patient to create an environment in which she or he feels safe, satisfied and heard.

Eleven sessions, over 25 hours, comprised of the following topics:

• Improvisation activities
• Introduction to case presentations
• Body language - contact improvisation
• Performance of story
• Neutral dialogue and elements of a narrative
• Narrative in context - what’s lost, what’s gained?
• Listening with a neutral mask
• Storytelling
• Writing and presenting case histories
• The art of personal monologue
• Final presentations with professional critique

Survey responses uniformly found that students valued this creative, non-traditional approach to learning about interpersonal communications and oral presentations. The art of focused storytelling to an audience  is exactly what physicians do every day when presenting clinical cases.


Reference
Hammer RR, et al. Telling the Patient's Story: using theatre training to improve case presentation skills. Medical humanities. 2011, 37(1), 18-22. PMID: 21593246
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Live blogging from annual UCSF Education Day

Today UCSF's Academy of Medical Educators (AME) and Office of Medical Education host the 10th annual Education Day. It is free to the public and features many of the big-hitters in medical education at UCSF. I'm hoping that my brain will absorb some of the good education ju-ju at the conference.

The schedule can be found here, featuring the keynote speaker Dr. Diane Wayne (Associate Professor and Vice-Chair of Education in the Department of Medicine at Northwestern University) discussing the "Use of Medical Education Research to Improve Patient Care Quality".



The last time I live-blogged (CORD Academic Assembly 2011), I embedded a Google Docs spreadsheet. The plus was that I had a lot of flexibility in how I could format the layout. The minus was that I needed a wireless internet connection and I couldn't do this from an iPad (doesn't allow Google Docs editing). So this time, I'm embedding a Twitter feed, knowing that I'll be limited to 140 characters. The up side is that I can do this on 3G or wireless and can more easily post photos on-the-fly. If you reply on Twitter, I'll try to respond in as real-time as possible. Let me know what you think.

Academic EM's Education Supplement: Deadline 4/22/11

I can't seem to find any posting anywhere online, but I know for a fact that if you want to submit a manuscript for publication in the CORD-CDEM Education Supplement in Academic Emergency Medicine, the deadline is April 22, 2011.

It's a great opportunity to feature your educational research or innovation. Take a look at last year's table of contents:

• 2010 Council of Emergency Medicine Residency Directors (CORD) Selected Abstracts
• It’s Time: An Argument for a National Emergency Medicine Education Research Center
• The CORD Academy for Scholarship in Education in Emergency Medicine
• Critical Appraisal of Emergency Medicine Educational Research: The Best Publications of 2009
• Emergency Medicine in the Medical School Curriculum
• Anatomy of a Clerkship Test 
• Inaccuracy of the Global Assessment Score in the Emergency Medicine Standard Letter of Recommendation 
• Emergency Medicine Quality Improvement and Patient Safety Curriculum 
• Curriculum Design of a Case-based Knowledge Translation Shift for Emergency Medicine Residents
• Rotating Resident Didactics in the Emergency Department: A Cross-sectional Survey on Current Curricular Practices 
• Incorporating Evidence-based Medicine into Resident Education: A CORD Survey of Faculty and Resident Expectations
• An Evaluation of Resident Work Profiles, Attending–Resident Teaching Interactions, and the Effect of Variations in Emergency Department Volume on Each
• A Core Competency–based Objective Structured Clinical Examination (OSCE) Can Predict Future Resident Performance
• Direct Observation Evaluations by Emergency Medicine Faculty Do Not Provide Data That Enhance Resident Assessment When Compared to Summative Quarterly Evaluations 
• Optimizing Resident Training: Results and Recommendations of the 2009 Council of Residency Directors Consensus Conference
• Scholarly Tracks in Emergency Medicine
• Guiding Principles for Resident Remediation: Recommendations of the CORD Remediation Task Force
• Best Educational Practices in Pediatric Emergency Medicine During Emergency Medicine Residency Training: Guiding Principles and Expert Recommendation

Article Review: Barriers to effective teaching

I think there is no better or more rewarding job than being an educator, especially in the field of Medicine.

There are, however, significant financial, societal, curricular, and environmental barriers which prevent optimally effective teaching in Medicine. In a commentary piece in Academic Medicine, the authors review the barriers and some forward-thinking recommendations for our leaders in medical academia. While the focus of the article is on undergraduate medical education, many concepts apply to graduate medical education as well.

Recommendations:

1. Establish and measure desired education outcomes of graduates. We need to agree upon and articulate what common skills and knowledge we expect from our medical school and residency graduates. For instance, should ALL medical students be proficient in a lumbar puncture? There are differences in opinion.
   
2. Determine acceptable evidence of performance proficiency and use. "Longitudinal performance-tracking systems" should be in place to ensure learners achieve key benchmark goals.
   
3. Build systems into the curriculum that will increase the capacity for strong patient–learner and teacher–learner relationships. Medical students should establish strong longitudinal ties with faculty mentors and have early clinical learning experiences during medical school. Extrapolating this to the GME arena, residents should find faculty mentors and start building their career track.
   
4.  Involve other health professionals as collaborators in the education mission. This enhances interdisciplinary collaboration and communication, while also reducing the need for clinical faculty time.
   
5. Require systems that recognize and reward excellence in teaching and educational scholarship and hold faculty accountable for the quality and amount of teaching. Academic faculty are expected to teach, as part of their academic responsibilities, and should be held accountable. Also, faculty development opportunities need to be available to help substandard performers improve their skills.
   
6. Allocate adequate space, budgets for supplies, professional resources, equipment, and compensation to optimize the education mission. We need to invest more in our educators, who often are uncompensated for their time to teach medical students and residents.
   
7. Recruit educational specialists with the appropriate expertise to optimize faculty efforts as clerkship or residency directors, course directors, or teachers. Even our educational leaders need mentorship. We can always get better. At UCSF, we have the Office of Educational Research and the Academy of Medical Educators to help educators with problems, faculty development, and mentorship. Take a look at your institution to see what's available.
   
8. Develop a national or global health care professions institute whose aim is to advance the development of health professions educators and educational research. Medical educators do not have a national organization for the specific purpose of improving faculty development and the quality of educational research. A national organization might offer certificate or degrees upon completion of a series of workshops or courses (such as the Medical Education Research Certificate (MERC) program hosted by the AAMC). By bring physicians from across specialties and sites, this would enable easier coordination and collaboration for large-scale multi-institutional studies.
9. Increase grant dollar availability for educational development and research in health professions education at the federal and local level. Show me the money.
   
10. Create an international health professions education statistics database. This would expand beyond the US Department of Education's National Center for Education Statistics (NCES) to identify common educational issues on the global level.

Research
Darosa DA, Skeff K, Friedland JA, Coburn M, Cox S, Pollart S, Oʼconnell M, Smith S. Barriers to Effective Teaching. Academic Medicine. 2011 - in early release. PMID: 21346500

Article Review: Emergency physicians interruptions

What exactly do ED attendings do on shift? 

This novel prospective, time-motion study tracks the activities of ED attendings at 2 academic and 2 community sites. All sites used paper charting in the ED and computerized medical records for labs and radiology results.

METHODS
Trained observers recorded tasks in 1-minute increments over a 2-hour period. Three general categories were defined as:

• Direct patient care (lifting patients, bedside history/physical exam, direct interaction with patient, ordering tests or medications, interpreting ECG, performing procedures)
• Indirect patient care (charting, reviewing records, teaching learners, interpretation of diagnostic tests, talking with patient's friends/family; interacting with nurses, paramedics, consultants, ancillary staff)
• Personal activity (waiting, eating, social conversation with colleague, surfing the internet)

Specifically, the observers tracked "interruptions", as defined as an event that briefly required the attention of the attending but did not result in switching to a new task. This included:

• Listening to an overhead announcement
• Nursing inquiry about another patient
• Quick update from a learner

Also "breaks in task" were also tracked, as defined as an interruption that resulted in changing tasks. Examples included answering incoming telephone call, stoping a procedure to care for a cardiac arrest patient.

Additional data points tracked included:

• Distance walked
• Patients touched
• Handwashing
• Time sitting
• Maximum # of patients under care

RESULTS
There were 203 two-hour observation periods (160 at academic sites, 43 at community sites). A total of 85 physicians were observed.

• The majority of time was spent performing indirect patient care. The median time was 61 minutes (academic) vs 55 minutes (community) over the 2-hour period.
• The median time for direct patient care was 36 minutes (academic) vs 41 minutes (community).
• The median number of different individuals interacted with was 35 (academic) vs 23 (community). Wow, we really do interact with a lot of people in a 2-hour period. I just never realized.
• Hand-washing occurred a median of 2 times at both the academic and community sites.
• Physicians walked a median of 0.3 miles (academic) vs 0.17 miles (community). I can definitely attest to all the walking, since I wore a pedometer several years ago. I used to walk over half a mile per 8-hour shift.

The most interesting finding is that interruptions occurred a median of 12 times (academic) vs 6 times (community). Furthermore, 5 of the 12 (academic) and 2 of the 6 (community) interruptions resulted in a "break in task".

BOTTOM LINE
The data from this study provide many interesting discussion points. For instance, emergency physicians need to have strong communication skills, since we interact with so many different individuals. Furthermore, it would be interesting to repeat this study with the implementation of an electronic medical record system in the ED. Would it decrease some of the inefficiencies?

Interruptions are definitely a part of our everyday lives when working the ED. It's more frequent in an academic institution, presumably because we work with medical students and residents who have questions and updates. Because interruptions are associated with a higher risk for medical errors, greater stress levels, and impaired task performance, we need to teach attendings (and EM residents) how to minimize and cope with interruptions.  It would be great if we could wear a "Do NOT Disturb" hat when we are already overwhelmed.

Kudos to the research team for coordinating and completing such a Herculean study. Can you imagine following attendings around for a total of 406 hours and tracking minute-to-minute activities?

Reference
Chisholm CD, Weaver CS, Whenmouth L, Giles B. A Task Analysis of Emergency Physician Activities in Academic and Community Settings. Annals of emergency medicine. 2011 - in press. PMID: 21276642
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Article review: Selected abstracts from 2010 CORD Academic Assembly (pt 3 of 3)

HAPPY NEW YEAR!

In the 2010 CORD-CDEM Supplement in Academic Emergency Medicine, 29 abstracts were selected from the CORD Academic Assembly. I reviewed the Abstracts #1-10 and Abstracts #11-19 last week. Here's a quick look at Abstracts #20-29. Maybe there's something that you might be interested in pursuing or reading more about. 

Medical Immediate Action Drill (MIAD) Cards for Core Content Review and Oral Exam Practice for Emergency Medicine Residents
Michael A. Bohrn, et al (York PA Hospital)

This educational innovation involves the creation of pocket cards which cover classic emergent conditions, such as acute angle glaucoma, massive GI bleed, and ventricular tachycardia. Each card contains the patient presentation and key assessment/management pearls. These cards can be used as an adjunct to mock oral boards sessions or for bedside teaching.

A Streamlined Pocket Reference for New Doctors
Joseph Habboush, et al (St. Luke’s-Roosevelt Hospital Center, Mt. Sinai Hospital, NY)

Pocket cards were created in this educational innovation, which focus on novice practitioners in the ED (eg. off-service rotations, interns, medical students). Each card details a brief description on how to approach a particular chief complaint, which includes a table of key differentials, initial management plan, and key documentation pearls.

No Place Like Home: Geographic Ties Positively Affect Residency Applicant Pool Characteristics
Matthew S. Dawson et al (University of Utah)

In its first two years of residency (2005, 2006), the Univ of Utah retrospectively assessed whether applicants with geographic ties to Utah were more competitive than those without ties. Of the 586 applicants, 67 (11.4%) had geographic ties. Those with ties were more likely to have attended a top-tier medical school (55.2% vs 40.3%, p=0.02). All other characteristics (competitiveness on the SLOR, board exam failure, medical school remediation, or previous failed residency match attempt), however, showed no difference. The authors conclude that geographical ties improves the applicant pool to new and potentially established residency programs.

Design Innovations and Barriers of a High Fidelity Simulated Emergency Center in Second Life

David J. Robinson, et al (University of Texas Medical School at Houston)

This educational innovation involves using the virtual simulation platform called Second Life. While there are many advantages to this platform, there are significant design and process challenges.

I’m Watching What you Do: Professionalism from the Students’ Point of View 

Sally A. Santen, Robin R. Hemphill (Emory University)

This qualitative study evaluated written reflections from 58 fourth-year medical students in an EM clerkship, who included issues of professionalism. The following themes were identified: determining if a patient has drug-seeking behavior, awareness of cynicism, unprofessional behavior by physician superiors, and issues of being subordinate in a hierarchical system.

How Do Emergency Medicine Clerkship Directors Select Visiting Medical Students?
Thomas Morrissey (University of Florida)

This survey study of CDEM members (n=59 responses) assessed how EM clerkship directors choose visiting students. 50% accepted students on a first-come, first-served basis and 25% screened student using transcripts, CVs, and letters. Not sure what the last 25% did.

Practice-Based Learning and Improvement (PBL-I) of the Resident and Residency Using the Annual ABEM In-Training Examination
Alison P. Southern (Summa Health System/NEOUCOM)

This educational innovation involved PGY-1 and PGY-2 residents self-identifying a learning plan immediately following the ABEM in-training examination. Twenty hours of online lectures were chosen for each resident prior to the next examination. Although this PBL-I approach did not result in improvement in exam scores, compared to historical controls, residents found the approach valuable.

Is Being Selected as a Chief Resident Necessary for a Career in Academics? 

Gabrielle Jacquet, et al (Multiple residency programs)

This multicenter, 5-year retrospective study assessed whether being an EM chief resident increases the likelihood of an academic career. Although there are several confounding factors, chief residents were found to be over twice more likely to pursue academics than non-chief residents.

Performance Improvement of Emergency Medicine Resident Clinical Care Using Objective Chart Assessment and Feedback
Richard D. Shih (Atlantic Health/Morristown (NJ) Memorial Hospital)

This 5-year prospective study evaluated the medical chart of EM residents at a single institution. Nine charts from each resident were randomly selected (3 chest pain, 3 abdominal pain, and 3 head trauma cases). Each chart was assessed on a 0-100 point scale based on objective measures. Charts from 48 residents were evaluated with the average chart scores being 84.5 (PGY-1), 84.0 (PGY-2), and 86.5 (PGY-3).

Effect of Crowding on Faculty Teaching Time in the Emergency Department
Michelle Lin, et al (Univ. of California, San Francisco)

OK, so this one is my abstract. Briefly, I conducted a prospective, observational, time-motion study of 19 unique attending shifts while supervising medical students and PGY-1 residents. A trained observer documented physician behavior during each 6-hour period. Crowding, based on the EDWIN (ED Work INdex), was associated with decreased teaching behaviors.

Article review: Selected abstracts from 2010 CORD Academic Assembly (pt 2 of 3)

In the 2010 CORD-CDEM Supplement in Academic Emergency Medicine, 29 abstracts were selected from the CORD Academic Assembly. I reviewed the Abstracts #1-10 last week. Here's a quick look at Abstracts #11-19. Maybe there's something that you might be interested in pursuing or reading more about. Personally, I love reading about what educational studies are ongoing on out there.

‘‘Are They Who They Say They Are?’’ New Behavioral-Based Interview Style 
Robert E. Thaxton, Robert J. Kacpowicz, John Rayfield (Wilford Hall Medical Center, USUHS and San Antonio Military EM Residency)

In this 2-year retrospective review of 32 residents to an EM program, 3 residents required disciplinary action. These 3 residents scored only 2.93 (on a scale of 1-10 with 10 being the best) on a behavioral-based scoresheet, which was based on a bank of standardized interview questions on leadership, motivation, flexibility, interpersonal skills, and decision making. Scoresheets were completed by faculty interviewers when these residents interviewed at their program. In contrast, the other 29 residents scored an average of 8.19. The authors conclude that professional behavior may be quantified and predicted by this interview approach.

Resident Values: Are They Important?
Robert E. Thaxton, John Rayfield (Wilford Hall Medical Center, USUHS and San Antonio Military EM Residency)

This 3-year retrospective study attempted to correlate resident disciplinary action with their interview question "Why is Medicine as a career important to you?"This interview was conducted upon entering the residency program by an APD. Responses were classified as either internal/personal focus or external/others focus. Of the 11 residents (of 78) who received disciplinary action, 8 had an internal focus and 3 had an external focus. Interestingly of the 8 with an internal focus, the disciplinary action involved areas of professionalism. Of the 3 with an external focus, the disciplinary action involved areas of medical knowledge (2) and professionalism (1).

Physician Perceptions of the Effect of Implementing a Standardized Written Plus Verbal Patient Sign-Out Process in an Academic Emergency Department 
Jason D. Heiner, Jason M. Desadier, Benjamin P. Harrison (Madigan Army Medical Center)

This survey study using a convenience sample of 31 participants (21 EM residents and 10 EM staff) studied their opinions of a combined verbal AND written sign-out process (i.e. handoff) in the ED. After implementation of the new sign-out process, 81% felt that the sign-out process was somewhat better or much better and 61% felt that their comfort with the sign-out plan was somewhat better of much better.

‘‘I Want a Real Doctor’’: The Effects of Physicians in Training on Patient Satisfaction in the Pediatric Emergency Department
Brian W. Walsh, Alex Troncosco (Morristown (NJ) Memorial Hospital)

This multicenter, 5-year, retrospective study looking at Press Ganey surveys at 4 pediatric EDs evaluated patient satisfaction scores for when a physician in training (student/resident) was present and absent. Results from 1,373 ED visits revealed that doctor satisfaction was very slightly lower (87.9 vs 86.4, mean difference 1.5, 95% CI 1.3 to 1.7) with a physician-in-training. Oddly, the likelihood that the patient would return was higher (85.4 vs 84.4, mean difference -1.0, 95% CI -1.7 to -1.3) with a physician-in-training. In the end, although these differences are statistically significant, they are very slight, conflicting. Physicians-in-training probably do not tremendously affect patient satisfaction.

Does Subspecialty Training Affect Patient Satisfaction? 
Brian W. Walsh, Elizabeth Haines (Morristown (NJ) Memorial Hospital)

This multicenter, 5-year retrospective study looking at Press Ganey surveys at 4 pediatric EDs evaluated "overall satisfaction", "satisfaction with doctor" and "likelihood to return" scores for EM-trained vs Pediatric EM-trained physicians. There was no difference across all three outcome measures.

Social Networking Websites and Internet Media As Residency Recruitment Tools 
Bjorn K. Peterson, Eric J. Dahl, Cullen B. Hegarty (Regions Hospital, St. Paul, MN)

This abstract describes a program's educational innovation to harnass social media platforms to promote their residency program to potential applicants. Short video clips give viewers an overview of the program were posted on YouTube and Facebook.

Teaching Academy for Emergency Medicine Faculty 
Michael A. Bohrn, David C. Vega, Noelle A Rotondo, Rebecca I. Bluett (York PA Hospital)

This abstract describes an EM department's education innovation in faculty development. EM faculty teach other EM faculty about bedside/clinical teaching over four 2-hour small-group sessions. These sessions cover bedside teaching, feedback and evaluations, teaching portfolios, and sharing of individual teaching projects.

Advanced Competency in Electrocardiography (ACE) Program for Emergency Medicine Residents
Michael A. Bohrn, Rebecca I. Bluett (York PA Hospital)

This abstract describes a residency's educational innovation in creating a certificate program in Advanced Competency in Electrocardiography (ACE) for only the top-performing EM residents. The certificate program requires that residents complete additional monthly assignments and self-study readings about advanced concepts in ECG interpretation.

Faculty Evaluations of Emergency Medicine Residents Using an Audience Response System Michael J. Rest and Laura J. Bontempo (Yale University School of Medicine, New Haven CT)

Faculty members often evaluate residents in a non-anonymous forum amongst other faculty. One program changed its practice by collecting faculty evaluation scores at a monthly meeting by an audience-response system (ARS), which is typically used in lectures. This allows for anonymous scoring and a platform where everyone's "voice" counts. This survey-based study assessed 17 or 24 (71% survey response rate) faculty members who felt that an ARS system increased the accuracy of resident evaluations.

Article review: Selected abstracts from 2010 CORD Academic Assembly

In the 2010 CORD-CDEM Supplement in Academic Emergency Medicine, 29 abstracts were selected from the CORD Academic Assembly. Here's a quick look at the first 10. Maybe there's something that you might be interested in pursuing or reading more about.

The Patient Experience: A Novel Educational Experience in the ACGME General Competencies

Catherine A. Marco, David F. Baehren, and Kristopher Brickman (University of Toledo, Toledo, OH)

In this retrospective survey study, 8 PGY-1 EM residents shadowed patients from triage to disposition and found positive and negative examples of the ACGME competencies - Professionalism, Systems Based Practice, Patient Care, and Interpersonal and Communication Skills.

Political Advocacy Project for Emergency Medicine Residency 

David C. Lee, Joseph LaMantia, Andrew E. Sama, and Theodore Sung (North Shore University Hospital)

The purpose of this curricular innovation was to enhance political awareness and action amongst emergency physicians. PGY-4 EM residents at the program were required to complete a political advocacy project where residents each studied a federal or local bill, summarized their findings to the EM program, and contacted their local political representative. 

Successfully Introducing Interns to Academic Medicine: A Curriculum for Participation in the Annual Society for Academic Medicine Meeting 

Jeffrey N. Love (Georgetown University/Washington Hospital Center)

This curricular innovation involved a structured experience for PGY-1 EM residents at the annual SAEM meeting, which included attending didactic sessions, select abstract presentations, and interest group meetings.  Upon their return, each resident then reported on 3 abstracts/papers at the departmental journal club.

The Effect of a Novel, Emergency Department Based Work-Study Program on Medical Students’ Perceived Skills and Clinical Competency 

M. Tyson Pillow, Shkelzen Hoxhaj, Angela Fisher, Donald Stader, and Theresa Tan (Baylor College of Medicine)

This retrospective survey study evaluated 1st year medical students who were provided the opportunity to participate in a work-study program where they learned how to perform phlebotomy, place peripheral IVs, and obtain ECGs in the ED. Eleven of the 53 respondents (21%) had participated in the work-study program. Compared to the non-participants, their comfort level on a 0-4 point scale were much better for phlebotomy (3.6 vs 0.2), IV placement (1.6 vs 0.1), and ECG acquisition (3.2 vs 0.6). 

Is Academic Productivity Amongst Emergency Physicians Affected by a Salary Incentive Plan?

Randy J. Hartman, Timothy C. Stallard, David L. Morgan, and Cindy F. Rush (Texas A&M University Health Sciences Center)

This retrospective observational study evaluated the consequence of an EM department's moving from an academic salary incentive plan (which rewarded scholarly activity, conference attendance, and completion of resident evaluations) to a clinical-based salary incentive plan (which rewarded clinical RVUs only). Results showed that the percentage of faculty submitting projects dropped by 62.5%, conference attendance decreased by 9.8%, and completed resident evaluations dropped by 24.7%.

EM-CROS: A Model for the Development of an Emergency Medicine Curriculum for Rotating Residents 

Tyler S. Jorgenson, Ian B. K. Martin, Kevin J. Biese, Cherri D. Hobgood (UNC-Chapel Hill School of Medicine)

This curricular innovation focuses on teaching off-service residents rotating in the ED. One article was selected in 7 core topics each-- chest pain, sepsis, altered mental status, shortness of breath, abdominal pain, headache, and cervical spine trauma. These articles and test questions were distributed to the residents for independent study. While on shift, the residents were encouraged to evaluate a variety of patient complaints, by having them each check off a card-based list of procedures and patient encounter objectives for the rotation period.

Medical Students’ Perceptions of an Emergency Medicine Clerkship: An Analysis of Self Assessment Surveys 

Jennifer A. Avegno, Heather Murphy-Lavoie, Lisa Moreno-Walton (Louisiana State University Health Sciences Center - New Orleans)

This 1-year survey study evaluated EM clerkship students' change in confidence level with patient management, resuscitations, oral presentations, procedural skills, and understanding of EM practice after completing an EM clerkship rotation. A secondary outcome measure was comparing these items between the 2- and 4-week clerkship groups. All of the students felt more comfortable with patient management and basic procedural skills after the EM clerkship. Students in the 2-week clerkship felt less confident in their formal presentation skills and most basic procedures (except ECG interpretation, splinting, and venipuncture) compared to those in the 4-week clerkship.

Reducing Unnecessary Administrative Time of Student Scheduling by Utilizing a Template System and Google Documents 

Jeffrey T. Van Dermark, Derek L. Kelly, and David deGive (UT Southwestern Medical Center at Dallas)

This curricular innovation empowered EM clerkship students by allowing them to select their own EM shift schedules based on a pre-templated schedule posted on Google Docs. Before the start of the rotation, students were allowed to decide amongst themselves who was assigned to each of the 10 evenly-weighted EM shift schedules. This significantly freed the administrative staff and clerkship director from burdensome administrative work to accomodate everyone's schedule requests.

Emergency Medicine Residents Exhibit Varied Learning Styles 

Nicole M. Deiorio and Donald E. Rosen (Oregon Health and Science University)

This survey-based study evaluated the learning styles of 30 EM residents based on the Kolb Learning Style Index. This self-assessment tool categorizes learners into Convergers, Divergers, Accomodators, and Assimilators. Amongst the 22 residents who responded,  59% were Convergers, 0% were Divergers, 23% were Accomodators, and 18% were Assimilators. With a variety of learning styles, the authors propose that the EM conferences and didactic curricula should be designed with this in mind.

Video Feedback to Students Can Be Easy and Inexpensive 

Nicole M. Deiorio and Ryan T. Palmer (Oregon Health and Science University)

This curricular innovation involves delivering feedback to medical students in a delayed fashion using video messaging. If real-time feedback is not possible, faculty can use a website (www.eyejot.com) to record and email their short video messages to the student for free. The authors hypothesize that subtle cues and nuances from the video format make the feedback more impactful than if done in text form.

Reference
Multiple authors. 2010 Council of Emergency Medicine Residency Directors (CORD) Selected Abstracts Acad Emerg Med. 2010. 17, Supplement: S1-S10. DOI: 10.1111/j.1553-2712.2010.00884.x