ABSTRACTBackgroundLaw enforcement is a common yet complicated presence in the emergency department (ED). Studies have found emergency medicine (EM) attending physicians have varied interactions with and attitudes toward law enforcement. EM resident physicians are in a uniquely formative professional period. However, the experiences and perspectives of EM resident physicians have not been previously explored in depth.MethodsWe recruited EM resident physicians from three geopolitically distinct urban academic EDs in the United States to participate in semi‐structured interviews regarding their experiences with law enforcement in the ED. We analyzed the transcripts thematically, looking for unifying concepts across institutions and latent meaning. A codebook was created and iteratively refined based on review of transcripts, after which salient themes were developed through ongoing discussions with the research team.ResultsTwenty‐four resident physicians across three sites participated. Three salient themes emerged from our study: ambiguity of authority between emergency physicians and law enforcement, concerns about the impact of law enforcement presence on patients, and disruptions to the ED team workflow. First, as trainees learning professional norms in the ED, participants reported difficulty navigating situations in which law enforcement attempted to assert authority over patient care. Second, participants perceived negative impacts of law enforcement presence on patients in custody and non‐incarcerated patients of color receiving care in the ED. Finally, participants described frequent disruptions to the ED team workflow due to the presence of law enforcement. Participants relied on hospital security, rather than law enforcement, to ensure the safety of patients and staff.ConclusionEmergency resident physicians described ambiguous boundaries and complex interactions among law enforcement, patients, and themselves in the ED. Although our study found several concerning impacts of law enforcement in the ED, these represent opportunities to clarify roles and responsibilities in the emergency physician‐law enforcement relationship and improve patient care. Further research is needed, including eliciting perspectives of law enforcement and patients, particularly those with substance use disorders, trauma, and serious mental illness.

Pediatric Emergency Medicine (PEM) fellowship programs use Milestones to assess fellows, but validity evidence for these ratings is needed. (1) Define benchmark levels of competence for the 6 Milestones competency domains and 23 competencies. (2) Determine if Milestones ratings at graduation predict passing the American Board of Pediatrics (ABP) certification exam. This multi-site retrospective cross-sectional study included all PEM fellows (2014-2022) from 80 programs in the U.S. who took the ABP certification exam. Milestones ratings from the Accreditation Council for Graduate Medical Education (ACGME) were provided to the Association of Pediatric Program Directors and analyzed. Logistic mixed effects regression models assessed associations between American Board of Pediatrics (ABP) exam pass rates and Milestones at graduation. Data from 1302 fellows (1171 from 3-year and 131 2-year graduates) yielded 90,229 Milestones ratings from which benchmarks were established. Systems-based practice consistently had the lowest mean across all fellowship years. 3-year graduates had significantly higher Milestones at graduation compared to 2-year graduates (p < 0.001). 3-year graduates with ABP certification had significantly higher graduating mean Milestone ratings averaged over all domains compared to those without evidence of certification (p = 0.003), but 2-year graduates had no significant difference (p = 0.78). This national study of PEM fellows establishes validity evidence for use of year-end Milestones ratings from fellowship within all domains as a potential predictor for achieving ABP certification exam. Fellows from 3-year programs had higher mean Milestones at graduation and higher certification exam pass rates.

The author declares no conflicts of interest. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Emergency medicine (EM) has experienced considerable expansion in recent years, prompting concern among potential EM applicants. This study reports the growth rate for training positions in EM and other specialties during three consecutive 5-year periods from 2011 to 2025, with the goal of providing context for medical students and their advisors as they assess EM's growth relative to other fields. This study analyzed National Residency Matching Program (NRMP) Main Residency Match data. The growth rate for first-year postgraduate (PGY-1) training positions was calculated for EM and eight other specialties from 2011 to 2015, 2016 to 2020, and 2021 to 2025, which correspond to the 5-year periods before, during, and after the transition to a single graduate medical education accreditation system. The percentage of total NRMP positions offered by each specialty was also calculated. The number of EM PGY-1 positions grew by 13.3% from 2011 to 2015, 40.6% from 2016 to 2020, and 8.0% from 2021 to 2025. Among the specialties included in this analysis, EM had the sixth highest growth rate from 2011 to 2015, the second highest growth rate from 2016 to 2020, and the seventh highest growth rate from 2021 to 2025. The proportion of EM positions, as a percentage of all NRMP PGY-1 positions, decreased from 2011 to 2015, increased from 2016 to 2020, and then decreased from 2021 to 2025. The growth rate for EM training positions offered through the NRMP increased during the transition to a single accreditation system, then slowed during the 5 years following the transition. From 2021 to 2025, the growth rate for EM positions was exceeded by anesthesiology, family medicine, general surgery, internal medicine, interventional radiology, and physical medicine and rehabilitation. These results demonstrate that the recent expansion in EM training opportunities is not unique.

Physician shadowing offers exposure to physicians' daily responsibilities, roles, and understanding of patient interactions. Given the pressure to maintain clinical productivity, including students in Emergency Department care may be difficult. Student impact on patient care and physician workflow is understudied, and novel programs seeking to incorporate students are warranted. We created a longitudinal educational program that combines physician mentorship and an in-depth clinical experience by offering more direct patient-facing activities compared with traditional volunteering or shadowing. We aimed to improve patient Emergency Department experience, incorporate students into the care team to improve the patient and family experience, and allow faculty to benefit from enhanced workflow by reducing the need for physician and nursing attention. Students served as a patient care concierge by carrying a mobile phone and providing patients with a business card with their phone number so they could be reached for questions, needs, or concerns. Students were not permitted to discuss test results, answer medical questions, or discuss care plans. The program has been modified based on feedback, which is obtained semi-annually. The patient task facilitator program has been active since 2019. Forty-two students and eight attending physicians have participated. Three students (7%) with engagement below expectations were removed from the program. Adaptations include ensuring consistent mentor pairing, increased phone availability, and internal promotion of the program. Faculty and student satisfaction was high; 74% of students reported plans to pursue careers in medicine, and faculty reported improved productivity, patient satisfaction, and nursing availability. Patients mentioned their patient task facilitator on Press Ganey surveys on multiple occasions as being positive and helpful, with no negative experiences noted. The Patient Task Facilitator program improved both students' and faculty's satisfaction with shadowing, and additionally improved attending productivity, nursing availability, and patient satisfaction.

The American Board of Emergency Medicine's new Certifying Exam features simulation-based assessment. The current resources available to prepare residents to pass this high-stakes exam are unknown. We sought to assess the current state of simulation resources and utilization in EM residency programs. This was a cross-sectional survey study of residency or simulation leadership at ACGME-accredited EM programs. We developed an online survey consisting of multiple-choice items, which was piloted before use. We collected data from August to December 2024. We calculated descriptive statistics, used chi-squared testing for categorical data comparisons, and Kruskal-Wallis for ordinal variables. Univariate logistic regression was used to examine associations between EM residency and simulation resource factors with annual simulation training hours. We identified contact information for 287 programs, and 194 completed the survey (67.6%). Most EM Residency programs had a simulation center (94.8%, 184/194). Fewer programs had simulation fellowship-trained physician faculty (44.3%, 86/194) or a division of simulation (40.7%, 79/194). Approximately 83% (161/194) of respondents felt that accessing simulation resources was easy or very easy. The median number of hours residents were engaged in simulation training per year was 40 (IQR 25-59). Univariate logistic regression found no association between EM program demographics and the annual number of hours of simulation training. The presence of simulation-trained faculty was associated with increased hours of simulation (OR 1.82, 95% CI 1.1-3.0, p = 0.05). While most participating EM residency programs have access to simulation resources, variability exists in resources and implementation across programs, which may lead to inequities in preparing trainees for the new ABEM Certifying Exam.

Completion of EM residency is essential for the growth of the specialty and the strength of each residency program. Understanding resident attrition is paramount for program leadership and recruitment. We aimed to determine if there was a change in EM resident attrition rates after the COVID-19 pandemic. We also sought to determine whether residency attrition rates correlated to attending attrition rates or EM residency application numbers. This was a retrospective cross-sectional study of publicly available data from the ACGME Data Resource Book from 2013 to 2023, NRMP Results and Data from 2014 to 2024, and the Medicare Physician and Other Practitioners database. When comparing the proportions of attrition between residents and attendings by year, the attending rate from 2 years prior was used, as we hypothesized a lag between attending and resident attrition based on structural factors in residency application and employment. To test whether attrition rates followed a similar pattern over time, slopes between residents and attendings were compared by year using a linear regression. A similar method was used to compare yearly resident attrition rate to annual application rates. Between 2014 and 2021, there was a general decline in EM resident attrition, followed by an increase in attrition in 2021-22. This pattern mirrored attending attrition rates with a two-year delay. Attending and resident attrition persisted at a higher-than-baseline rate in 2021 and the 2022-23 academic years, respectively. Lower-than-baseline application rates by these students persisted in the 2022-23 academic year, as did higher-than-baseline resident attrition rates. We found a spike in EM resident attrition for the 2021-22 academic year after a period of decline, mirroring trends in EM attending attrition, and an inverse correlation between EM residency application and attrition rates after 2021-22. Further studies are needed to elucidate the underlying factors determining resident attrition, attending attrition, and EM residency application.

Clinical handover (or handoff), the transfer of patient care between providers, is essential in Emergency Medicine. Poor communication during handover can threaten patient safety. Existing literature views handover as an information transfer; little research has examined the human interaction within handover and how it affects patient safety. We sought a more nuanced understanding of handover to improve this critical aspect of Emergency Medicine care. We used constructivist grounded theory to explore handover as a social phenomenon. We invited staff emergency physicians in an academic, tertiary care hospital to participate in semi-structured interviews, which were recorded, de-identified, and transcribed. The research team analyzed the transcripts in multiple progressively interpretive analytical stages: initial, focused, and theoretical. Cultural-Historical Activity Theory (CHAT) provided a framework for our data analysis. CHAT situates an individual's action into an activity system in which components interact, producing tensions. We sought to attain theoretical sufficiency by revising the interview guide and recruiting participants for specific insights. We interviewed sixteen (16) participants. During handover, the object was for the incoming physician (IP) to accept the handover plan from the outgoing physician (OP). We identified a rule requiring minimal handover plans that were realistic and dichotomous. The divisions of labor were tasks. During the interaction, emotional reactions such as judgment or compassion, and behavioral reactions such as pushback or acceptance could have resulted. There were unintended consequences from the handover process that impacted members' self-worth and generated threats to patient safety. We built a novel and more nuanced framework of handover in the emergency department that involves multiple interactions and tensions. Using this new model, emergency departments should adjust their handover processes to enhance group dynamics and patient safety.