Emergency Medicine Milestones: The Next Step.

Emergency medicine (EM) physicians commonly care for patients with serious life-limiting illness. Hospice and palliative medicine (HPM) is a subspecialty pathway of EM. Although a subspecialty level of practice requires additional training, primary-level skills of HPM such as effective communication and symptom management are part of routine clinical care and expected of EM residents. However, unlike EM residency curricula in disciplines like trauma and ultrasound, there is no nationally defined HPM curriculum for EM resident training. An expert consensus group was convened with the aim of defining content areas and competencies for HPM primary-level practice in the ED setting. Our overall objective was to develop HPM milestones within a competency framework that is relevant to the practice of EM. The American College of Emergency Physicians Palliative Medicine Sectionassembled a committee that included academic EM faculty, community EM physicians, EM residents, and nurses, all with interest and expertise in curricular design and palliative medicine. The committee peer reviewed and assessed HPM content for validity and importance to EM residency training. A topic list was developed with three domains: provider skill set, clinical recognition of HPM needs, and logistic understanding related to HPM in the ED. The group also developed milestones in HPM-EM to identify relevant knowledge, skills, and behaviors using the framework modeled after the Accreditation Council for Graduate Medical Education (ACGME) EM milestones. This framework was chosen to make the product as user-friendly and familiar as possible to facilitate use by EM educators. Educators in EM residency programs now have access to HPM content areas and milestones relevant to EM practice that can be used for curriculum development in EM residency programs. The HPM-EM skills/competencies presented herein are structured in a familiar milestone framework that is modeled after the widely accepted ACGME EM milestones.

A Cross-Sectional Study of Medical Student Knowledge of Evidence-Based Medicine as Measured by the Fresno Test of Evidence-Based Medicine

The prevalence of workplace mistreatment and its association with the well-being of emergency medicine (EM) residents is unclear. More information about the sources of mistreatment might encourage residency leadership to develop and implement more effective strategies to improve professional well-being not only during residency but also throughout the physician's career. To examine the prevalence, types, and sources of perceived workplace mistreatment during training among EM residents in the US and the association between mistreatment and suicidal ideation. In this survey study conducted from February 25 to 29, 2020, all residents enrolled in EM residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME) who participated in the 2020 American Board of Emergency Medicine computer-based In-training Examination were invited to participate. A multiple-choice, 35-item survey was administered after the examination asking residents to self-report the frequency, sources, and types of mistreatment experienced during residency training and whether they had suicidal thoughts. The types and frequency of workplace mistreatment and the sources of the mistreatment were identified, and rates of self-reported suicidality were obtained. Multivariable logistic regression models were used to examine resident and program characteristics associated with suicidal thoughts. Of 8162 eligible EM residents, 7680 (94.1%) responded to at least 1 question on the survey; 6503 (79.7%) completed the survey in its entirety. A total of 243 ACGME-accredited residency programs participated, and 1 did not. The study cohort included 4768 male residents (62.1%), 2698 female residents (35.1%), 4919 non-Hispanic White residents (64.0%), 2620 residents from other racial/ethnic groups (Alaska Native, American Indian, Asian or Pacific Islander, African American, Mexican American, Native Hawaiian, Puerto Rican, other Hispanic, or mixed or other race) (34.1%), 483 residents who identified as lesbian, gay, bisexual, transgender, queer, or other (LGBTQ+) (6.3%), and 5951 residents who were married or in a relationship (77.5%). Of the total participants, 3463 (45.1%) reported exposure to some type of workplace mistreatment (eg, discrimination, abuse, or harassment) during the most recent academic year. A frequent source of mistreatment was identified as patients and/or patients' families; 1234 respondents (58.7%) reported gender discrimination, 867 (67.5%) racial discrimination, 282 (85.2%) physical abuse, and 723 (69.1%) sexual harassment from patients and/or family members. Suicidal thoughts occurring during the past year were reported by 178 residents (2.5%), with similar prevalence by gender (108 men [2.4%]; 59 women [2.4%]) and race/ethnicity (113 non-Hispanic White residents [2.4%]; 65 residents from other racial/ethnic groups [2.7%]). In this survey study, EM residents reported that workplace mistreatment occurred frequently. The findings suggest common sources of mistreatment for which educational interventions may be developed to help ensure resident wellness and career satisfaction.

Exploring the Relationship Between the American Board of Emergency Medicine In-Training Exam Scores and Mandatory Didactic Attendance for Emergency Medicine Residents

Piloting a certification process for emergency medicine residency graduates in Kosovo

On July 1, 2013, the first group of programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) transitioned into the Next Accreditation System (NAS), and 1 year later, the remaining accredited specialties, the transitional year, and the review of sponsoring institutions will move into the NAS.1 The NAS is an outcomes-based and improvement-focused approach to the accreditation of programs and sponsoring institutions. The intent is to both ensure a level of quality (through assessment of compliance with the accreditation standards) and to promote ongoing improvement in all programs and innovation in high-performing programs.1 The added focus on improvement will be achieved through (1) a Self Study that each program will complete before its 10-year site visit and includes aggregation and analysis of data on its longitudinal improvement effort, and (2) a Self Study site visit during which the program will describe its improvement process and the outcomes achieved. The Self Study site visit will occur approximately 1 year after the program begins its Self Study.The lengthening of site visit intervals in the NAS and the focus on outcomes and continuous improvement call for a new type of site visit, and this new model requires testing. To further inform the Self Study and to increase its relevance to programs, the ACGME envisioned a new focus on programs' aims, combined with an environmental assessment that focuses on strengths, areas for improvement, opportunities, and threats.A key aim in the NAS is to reduce the burden of accreditation, and a recognized source of burden is the preparation of site visit documentation. Thus, the Self Study site visit also calls for a new approach to reporting that provides insight into programs' longitudinal improvement efforts, without that documentation either adding undue burden or affecting the ability of the program to conduct a complete and honest accounting of its strengths and its areas in need of improvement.The Self Study approach is currently being refined, with the first Self Studies for programs in Phase I of the NAS scheduled to begin in 2014, and the first Self Study site visits planned for 2015. In this brief article, we offer early information from the ongoing, conceptual testing of the Self Study site visit.By 2012, the aims and content of the 10-year Self Study and Self Study site visit (box 1) had evolved sufficiently to allow the ACGME to test the new elements of the proposed approach. This included the enhanced focus on program improvement, using the Annual Program Evaluation, and the new focus on program aims and an assessment of programs' performance and opportunities and threats in their local environment.In appreciation of the significant development the Self Study process and the new type of site visit would require, ACGME leadership thought it would be beneficial to test the emerging concepts and approaches in a sample of Self Study test visits, beginning in late 2012. It was clear that a “real” Self Study site visit would have required the programs to have completed a self-assessment and that the test visits would test only selected elements of the planned approach.To date, site visits at 3 institutions involving internal medicine and plastic and vascular surgery core programs and subspecialty programs in those areas have been completed. Test visits involved volunteer institutions, and the findings were not shared with Residency Review Committees. All test site visit programs were visited by a team, as is planned for the actual Self Study site visits. The individuals interviewed and the time commitment for participants on the day of the site visit were comparable to a “regular” site visit. The ACGME sought to ensure that preparation before a site visit would be minimal, and the site visit was limited to asking the residents or fellows in the test programs to complete a consensus list of program strengths and areas for improvement.The test visit entailed a debriefing with site visitors and program participants and produced reports for internal sharing and comprehensive field notes. In contrast to the more general compliance focus that had characterized earlier tests of Program Information Form-less site visits,2 these visits tested selected new elements planned for future Self Study visits. They included a focus onItems 2 through 4 above constituted an initial test of new dimensions the ACGME envisioned as part of a future NAS 10-year Self Study site visit. One of the key information items for this portion of the visit was the Annual Program Evaluation. To continue to preserve the ability of programs to conduct a frank assessment of areas for improvement, the test visits maintained the confidentiality of the Annual Program Evaluation, and the team asked the program director to discuss program improvement, articulating successes achieved and areas still being worked on, based on the several recent Annual Program Evaluations. The ACGME envisions that a similar approach will be used for actual Self Study visits.Although the sample is small, the test site visits to date have confirmed the feasibility and “assess-ability” of the added dimensions of a Self Study visit. Programs articulated “aims” without difficulty, although, other than efforts to address lower than desirable board performance, offering general information on preparing residents for academic careers, and in 1 instance, starting a primary care track, respondents were less clear about their ongoing activities to enhance performance relevant to these aims.Discussion during the assessment of strengths, areas for improvement, opportunities, and threats focused primarily on national threats, particularly changes in federal support for graduate medical education (GME). Local opportunities and threats were less readily identified in the conversations with program leadership. This suggests that these new site visit dimensions would benefit from ongoing assessment over time, and it is expected that these areas would be more developed in a “real” Self Study, which would have been preceded by a formal Self Study process.The early test site visits also highlighted several areas of emerging focus, some likely prompted by the increased emphasis on educational outcomes in the NAS. During the site visits, programs discussed new modes of evaluation on the Milestones; on initiatives to restructure their didactic programs, focusing on scheduling and delivery models to maximize access and participation; and on measuring the effect of the didactic offerings. Preparation for the board examination, as the most visible element of outcomes focus in the current system, constituted a major focus of the discussion of educational outcomes across programs at the programs sites visited to date. Another focal area likely resulted from new roles for faculty in the NAS, particularly professional development for assessing performance on the milestones and participation on Clinical Competency Committees. In addition to faculty development content, discussions addressed approaches to encourage participation, including scheduling strategies and financial and other incentives, such as academic promotion and recognition.Finally, the visits highlighted some beneficial approaches for tracking data on longitudinal improvement, using simple, common institutional formats that allowed programs to record and report their improvements and areas still being worked on. This longitudinal tracking of improvement will gain in importance in the NAS, as much of the focus of the Self Study visit will be on programs' effectiveness in making ongoing improvements.The early tests contributed significantly to the development and refinements of the program Self Study approach and the associated site visits envisioned for the NAS. This work will continue with a focus on (1) offering guidance to programs about effective and efficient approaches for longitudinal improvement, including sessions at the ACGME Annual Educational Conference; (2) developing a report that aggregates NAS performance data the ACGME would provide to programs at the “kick-off” of their Self Study effort, approximately 1 year before the scheduled site visit; and (3) formulating a succinct document for programs to complete in preparation for a Self Study site visit.During the early test visits, it became clear that a truly meaningful Self Study visit would require the prior completion of a Self Study process. The concept is widely used in educational accreditation, yet it remains one of the more debated elements. The ideal approach for an NAS Self Study would produce a self-assessment that aids in the acquisition of knowledge about the program and identifies areas of real, tangible improvements.3 At the same time, organizational and programmatic Self Studies, although valuable from an improvement perspective, carry significant time, financial, and opportunity costs.4 It is clear that, given the smaller size of residency programs or even a core programs and its associated subspecialty programs compared with universities or medical schools and the resource constraints in the GME environment, the Self Study approach will need to be adapted and streamlined for use in the NAS. It also became apparent that the process would need to address scheduling challenges for programs, particularly when core programs and their subspecialty programs are seen as a group, as is planned in the NAS. The rationale and anticipated benefits for having a collective Self Study and Self Study site visit for core programs and their associated subspecialty programs are shown in box 2.The exploration of elements of the Self Study and the associated visit confirmed the feasibility of the approach and acceptance by program and institutional participants, although the sample was limited and the use of the information for internal improvement may have produced a more receptive and less critical audience. Future challenges and areas to further develop and refine the site visit approach in the NAS will need to deal with efforts to assess programs' ongoing focus on improvement while ensuring the confidentiality of the data underlying that process.Additional site visits are planned, with a particular focus on tapping into programs' ongoing improvement efforts, and how those efforts could be documented without impinging on their ability to conduct frank and forthright assessments of strengths and areas for improvement. Future work will also explore formats that offer added value to programs, such as a Self Study or site visit that yields valuable insight for programs in key areas, particularly recognition of opportunities and threats within their environment.

Implementing the Next Accreditation System: Results of the 2014-2015 Annual Data Review.

The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project has shifted the focus for accrediting residency training programs from structure and process to documented outcomes. A central part of the ACGME's Next Accreditation System (NAS) is “articulating milestones of competency development in each discipline.”1 Resident achievement of educational Milestones will be an indicator of the educational effectiveness of residency programs. Most specialties have developed their Milestones through a collaborative effort involving representatives from the ACGME, the pertinent American Board of Medical Specialties (ABMS) organization, the pertinent professional specialty society, and the pertinent program directors' association. In contrast, the approach was quite different for Transitional Year (TY) residency programs, which comprise only 1 year of accredited postgraduate medical education, where there is no corresponding ABMS board certification entity or professional specialty society. In addition, graduates of TY training programs are not expected to demonstrate sufficient competency to enter the independent practice of medicine, as is the case with other specialty (categorical) residency programs.

Report of the Task Force on Residency Training Information (1999-2000), American Board of Emergency Medicine

Rural emergency departments (EDs) in the United States are less likely to be staffed with emergency medicine (EM) residency-trained and American Board of Emergency Medicine (ABEM)-certified physicians than urban EDs. Rural EM clinical experiences during residency training have been suggested as a strategy to encourage future rural practice, but past Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Emergency Medicine program requirements and a lack of familiarity with rural rotations in the EM graduate medical education (GME) community have limited their availability. To provide a template for the development and implementation of a rural EM clinical experience, Kern's six-step approach was followed.

Although the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine require clinical ethics education in residency training, instruction varies widely. We assessed the educational preparedness of trainees in emergency medicine to address ethics challenges common to their field. The survey assessed two outcomes: 1) knowledge of specific ethical challenges and 2) perceived educational preparedness, across five ethics areas: 1) informed consent and decisional-capacity assessment, 2) surrogate decision making, 3) interpretation of advanced directives, 4) withdrawing and/or withholding life support, and 5) presumed consent for emergency treatment. Clinical vignettes, revised through expert panel review and pilot testing, were utilized to evaluate these areas. The final instrument was administered via Web link to emergency medicine residents and recent graduates through adverts within Emergency Medicine Residency Association and Society for Academic Emergency Medicine (SAEM) newsletters and social media platforms. Additionally, targeted e-mails through the Council of Residency Directors in Emergency Medicine, the Clerkship Directors of Emergency Medicine, and the SAEM Ethics Committee listservs encouraged survey distribution. Analyses involved one-way analysis of variance for overall knowledge scores and chi-square tests for categorical outcomes. Multivariable regression models tested associations between respondent characteristics and outcomes. There were 302 participants of which 34% reported having a dedicated ethics module within their residency curriculum. The mean (±SD) knowledge score was 59.7% (±12.8%); assessing decisional capacity was the most difficult topic for respondents as only 1% both correctly addressed the general issue and identified the correct plan of action. Participants having a dedicated ethics module perceived themselves better prepared, although there was no association between having a dedicated ethics module and knowledge scores. Gaps in clinical ethics knowledge appear prevalent among emergency medicine trainees, and few programs have dedicated ethics modules. Greater study is needed to understand and remedy clinical ethics knowledge shortfalls.

To determine the morningness-eveningness (ME) distribution of emergency medicine (EM) residents. A voluntary, modified ME questionnaire was administered to all EM residents in the United States at the time of the 1995 American Board of Emergency Medicine's annual In-Training Examination. Seventy-eight percent (2,047/2,614) of the surveys were returned. ME scores ranged from 24 to 76, with a median score of 49 (interquartile range 44, 56). The scores were distributed differently from those of the normal population (p < 0.001), being skewed toward eveningness. There was a correlation (r = 0.13, p < 0.0001) between resident age and ME score, with older residents being more morning-oriented. Males were more morning-oriented than females (p = 0.005), and respondents with children living at home also were significantly more morning-oriented (p < 0.001). Stepwise logistic regression showed that the influence of age, gender, and children was cumulative (r = 0.19) but accounted for only 4% of the observed variability. EM residents are distributed differently from the normal population in terms of their ME preferences, tending slightly toward eveningness. The importance of this distribution in EM residents in unknown. A longitudinal follow-up of this cohort may help to determine the association of ME preference with overall practice satisfaction, tolerance of shift work, and career longevity.

BackgroundThe in-training examination is a national and yearly exam administered by the American Board of Emergency Medicine to all emergency medicine residents in the USA. The purpose of the examination is to evaluate a resident’s progress toward obtaining the fundamental knowledge to practice independent emergency medicine.AimsThe purpose of this study was to determine the effects of a 40 hour board review lecture course on the resident in-training examination in emergency medicine.MethodsA 40 hour board review lecture course was designed and implemented during the weekly 5 hour long resident conferences during the 8 weeks preceding the in-training examination date in 2006. Attendance was mandatory at the Accreditation Council for Graduate Medical Education (ACGME) standard of 70% or greater. A positive result was considered to be a 10% increase or greater in the resident’s individual national class percentile ranking among their national peers for their class year for the emergency medicine in-training examination. A resident was excluded from the study if there was no 2005 in-training examination score for self-comparison. The 95% confidence intervals (CI) were used to analyze the results.ResultsOf 16 residents, 1 (6.25%; 95% CI: 0–18%) showed a positive result of increasing their national class percentile ranking by 10% or greater. For the PGY2, one of the eight had a positive result (12.5%; 95% CI: 0–35.4%). For PGY3, no resident (0%; 95% CI: 0–35.4%) had a positive result.ConclusionsA 40 hour board review lecture course has no positive effect on improving a resident’s in-training examination score.

Understanding Accreditation Council for Graduate Medical Education (ACGME) Guidelines: Resident and Program Director Interpretation of Work-Hour Restrictions

Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and didactic education is insufficient. An asynchronous e-learning curriculum has not been studied across multiple centers in the context of a clinical rotation. We hypothesize that an asynchronous e-learning curriculum during the pediatric emergency medicine (EM) rotation improves medical knowledge among residents and students across multiple participating centers. Trainees on pediatric EM rotations at four large pediatric centers from 2012 to 2013 were randomized in a Solomon four-group design. The experimental arms received an asynchronous e-learning curriculum consisting of nine Web-based, interactive, peer-reviewed Flash/HTML5 modules. Postrotation testing and in-training examination (ITE) scores quantified improvements in knowledge. A 2 × 2 analysis of covariance (ANCOVA) tested interaction and main effects, and Pearson's correlation tested associations between module usage, scores, and ITE scores. A total of 256 of 458 participants completed all study elements; 104 had access to asynchronous e-learning modules, and 152 were controls who used the current education standards. No pretest sensitization was found (p = 0.75). Use of asynchronous e-learning modules was associated with an improvement in posttest scores (p < 0.001), from a mean score of 18.45 (95% confidence interval [CI] = 17.92 to 18.98) to 21.30 (95% CI = 20.69 to 21.91), a large effect (partial η(2) = 0.19). Posttest scores correlated with ITE scores (r(2) = 0.14, p < 0.001) among pediatric residents. Asynchronous e-learning is an effective educational tool to improve knowledge in a clinical rotation. Web-based asynchronous e-learning is a promising modality to standardize education among multiple institutions with common curricula, particularly in clinical rotations where scheduling difficulties, seasonality, and variable experiences limit in-hospital learning.