Depression among Emergency Medicine Residents over an Academic Year

Objectives: To describe the frequency of depression among emergency medicine (EM) residents by month, gender, rotation type, postgraduate year (PGY), and number of hours worked.
Methods: This was a prospective, nonblinded, cohort study of consenting EM residents in a four-year, 51-resident EM residency program from July 2003 to June 2004. Participants received an anonymous monthly survey via Web site that consisted of the Center for Epidemiologic Studies Depression Scale (CESD) and the resident's gender, PGY, number of hours worked in the previous week (≤40, 41–60, 61–80 and >80), and rotation type (EM, intensive care unit, non-EM clinical, or other). Residents were excluded from analysis if they did not complete at least one survey during each season. For each resident, the peak score for each three-month period was recorded and analyzed with a mixed-model analysis of variance to account for a repeated-measures effect.
Results: Fifty of 51 (98.0%) residents consented for participation. Nineteen (38%) were excluded because of incomplete data. The prevalence of depression was 12.1% (95% confidence interval [95% CI] = 7.5% to 19.0%; 15 of 124 scores). The women had numerically, but not statistically, significantly lower mean ± standard deviation CESD scores than the men (6.4 ± 6.8 vs. 8.7 ± 8.6, p = 1.0). There was no significant difference in mean CESD score by month, PGY, rotation type, or number of hours worked.
Conclusions: Season, number of hours worked, rotation type, PGY, and gender all failed to predict depression among EM residents in this single-center trial. The prevalence of depression was comparable to that of the general population.     

Rate of Patient Workups by Non–Emergency Medicine Residents in an Academic Emergency Department

Objective: To quantify the number of patients seen per hour by non–emergency medicine (non–EM) residents in a university hospital ED.
Methods: This retrospective observational study was performed in a university hospital ED and level I trauma center. The facility had no EM residency, but was staffed with 24–hour EM faculty coverage. A computerized tracking system was searched for the number of patients seen by each of 93 non–EM residents for 12 nonconsecutive months. The ED schedule for each month was used to calculate the number of hours worked by each resident. From these figures, the number of patients seen per hour by each resident was calculated.
Results: The postgraduate years of training of the residents were as follows: 78 (84%) were PGY1, ten (11%) were PGY2, and five (5%) were PGY3. All the residents combined saw a mean 0. 95 ± 0. 20 patients/ hour, with a range from 0. 58 to 1. 75 patients/hour. There was no significant difference between the numbers of patients seen when compared by specialty using the Tukey–Kramer test (α = 0. 05).
Conclusion: The rate at which non–EM residents work up patients is consistent with previously reported rates for EM residents.     

Can Unannounced Standardized Patients Assess Professionalism and Communication Skills in the Emergency Department?

Objectives:  The authors piloted unannounced standardized patients (USPs) in an emergency medicine (EM) residency to test feasibility, acceptability, and performance assessment of professionalism and communication skills.
Methods:  Fifteen postgraduate year (PGY)-2 EM residents were scheduled to be visited by two USPs while working in the emergency department (ED). Multidisciplinary support was utilized to ensure successful USP introduction. Scores (% well done) were calculated for communication and professionalism skills using a 26-item, behaviorally anchored checklist. Residents' attitudes toward USPs and USP detection were also surveyed.
Results:  Of 27 USP encounters attempted, 17 (62%) were successfully completed. The detection rate was 44%. Eighty-three percent of residents who encountered a USP felt that the encounter did not hinder daily practice and did not make them uncomfortable (86%) or suspicious of patients (71%). Overall, residents received a mean score of 60% for communication items rated "well done" (SD ± 28%, range = 23%–100%) and 53% of professionalism items "well done" (SD ± 20%, range = 23%-85%). Residents' communication skills were weakest for patient education and counseling (mean = 43%, SD ± 31%), compared with information gathering (68%, SD ± 36% and relationship development (62%, SD ± 32%). Scores of residents who detected USPs did not differ from those who had not.
Conclusions:  Implementing USPs in the ED is feasible and acceptable to staff. The unpredictability of the ED, specifically resident schedules, accounted for most incomplete encounters. USPs may represent a new way to assess real-time resident physician performance without the need for faculty resources or the bias introduced by direct observation.     

Resident Service Hours in Emergency Medicine

Objective: The number of hours worked by residents in all specialties has become a controversial issue. Residents often are expected to competently conduct patient care activities and to take educational advantage of clinical experiences in spite of frequent fatigue and sleep deprivation. This survey of residency directors was designed to assess the scheduled clinical time for emergency medicine (EM) residents. Methods: A 13-question survey dealing with time commitments of EM residents was sent to the residency directors of all accredited EM residency programs in the United States in the fall of 1991. Residency directors were asked to indicate the number of shifts, hours, and days off per week; and the number of night shifts and weekend days off per month for each postgraduate year of residency training (PGY1-PGY4). Directors also were asked whether shifts were scheduled randomly or predictably with progression from days to nights with time off after nights. Results: Seventy of 71 (98.6% response rate) residency directors responded. Residents were scheduled for an average of 49.1 hours per week. Scheduled hours decreased from an average of 51.9 at the PGY1 level to an average of 44.5 at the PGY4 level. A similar progression with year of training was noted for scheduled night shifts/ month, days off/week, and weekend days off/month. A PGY1 trainee averaged 7.0 night shifts/month, 1.9 days off/week, and 3.0 weekend days off/month; while a PGY4 trainee averaged 5.3, 2.4, and 3.2, respectively. Only 40% of the directors reported predictable scheduling progressing from days to nights. Conclusion: Emergency medicine resident schedules, as reported by residency directors, fall well within current specialty-specific requirements and compare favorably with the reported numbers for other specialties. However, because large ranges in scheduling parameters were reported, the data may be of value to residency directors, residents, and prospective residents. Most programs did not report a predictable schedule progression of shifts.     

Resident Efficiency in a Pediatric Emergency Department

Objectives: To measure the hourly rate of patients evaluated and treated by resident physicians in an academic pediatric emergency department (PED) and examine differences in the rate by subspecialty and year of training. Methods: For all residents rotating in an academic, urban children's hospital PED, the rate of patients seen per hour over the course of their rotation was calculated using an electronic tracking system, EmSTAT, for calendar year 2000. Rates are reported as the mean number of patients seen per resident hour worked. Mean differences are reported for resident subspecialties (emergency medicine, pediatrics, and family practice) and postgraduate year (PGY1–PGY3), and subclass comparisons were made with an analysis of variance test with Tukey's post hoc analysis. Results: A total of 153 residents (63.4% pediatric, 18.9% family practice, and 17.7% emergency medicine) saw 24,414 patients during the study period. The makeup of the group by training year was as follows: PGY1, 20.9%; PGY2, 41.2%; and PGY3, 37.9%. For all residents, the mean rate was 1.02 patients seen per hour (pph). Significant differences in the mean number of patients seen per hour by subspecialty existed, with emergency medicine residents seeing a mean of 1.12 pph, pediatrics residents seeing 1.02 pph, and family practice residents seeing 0.93 pph (mean difference, p < 0.05 for all comparisons). Rates increased by year of training, with PGY1 seeing a mean of 0.95 pph, PGY2 seeing 0.99 pph, and PGY3 seeing 1.09 pph (mean difference, p < 0.05 for all comparisons except PGY1 vs. PGY2). Conclusions: Significant differences in the rate of patients evaluated and treated in the PED exist by resident subspecialty and year of training. Knowing these rates is helpful in evaluation of resident performance, because it allows comparison with peers. Additionally, such information may be useful for residency program evaluators to gauge the amount of patient exposure for residents.     

Analysis of junior doctor supervision in Australasian emergency departments

Background: Supervision of junior doctors in ED is vital but limited literature exists on how it is provided. Objective: To assess Australasian ED supervision and review regional legislature supervision requirements. Methods: Between December 2008 and June 2009 emails containing a link to a cross‐sectional survey were sent to Directors of Emergency Medicine Training in all Australasian ED accredited for advanced training. Non‐responding ED were subsequently contacted by telephone or email. Regional legislature supervision requirements were obtained from postgraduate medical councils. Results: A total of 103 (98.1%) of 105 ED participated. Senior review in person was mandatory in 43.2% of ED for patients of PGY1 (postgraduate year 1 doctors) and 6.1% of ED for patients of PGY2 (P < 0.001). Of ED without mandatory review, 13% had written guidelines detailing which patients required review. When ED consultants were on‐site, they most commonly provided supervision in 60.2% of ED and shared supervision equally with registrars in 35.7% of ED; when consultants were off‐site registrars most commonly provided supervision in 87.6% of ED. Fewer major regional/rural base hospitals had 24 h PGY3 or above supervision than major referral and urban district hospitals (82.6% vs 100% and 100%, P < 0.01). Regional legislature requirements varied with no universal guidelines. Conclusion: There are significant differences between supervision requirements for PGY1 and PGY2. A minority of ED in Australasia do not have 24 h supervision by PGY3 or higher. Few ED have written guidelines for supervising PGY1 and PGY2. The majority of registrar supervision occurs without consultant oversight. Legislature requirements for supervision in ED are variable between regions.     

Report from the Council of Emergency Medicine Residency Directors Subcommittee on Graduate Medical Education Funding: Effects of Decreased Medicare Support

INTRODUCTION: Recent changes by the Health Care Financing Administration (HCFA) have resulted in decreased Medicare support for emergency medicine (EM) residencies. OBJECTIVE: To determine the effects of reduced graduate medical education (GME) funding support on residency size, resident rotations, and support for a fourth postgraduate year (PGY) of training and for residents with previous training. METHODS: A 36-question survey was developed by the Council of Emergency Medicine Residency Directors (CORD) committee on GME funding and sent to all 122 EM program directors (PDs). Responses were collected by the Society for Academic Emergency Medicine (SAEM) office and blinded with respect to the institution. RESULTS: Of 122 programs, 109 (89%) responded, of which 78 were PGY 1-3 programs, 19 were PGY 2-4, and 12 were PGY 1-4. The PDs were asked specifically whether there were changes in program size due to changes in Medicare reimbursement. Although few programs (12%) decreased their size or planned to decrease their size, 39% had discussions regarding decreasing their size. Thirty percent of the PDs responded that other programs at their institution had already decreased their size; 26% of the PDs had problems with financing outside rotations; and 24% had a decrease in off-service residents in their emergency departments (EDs). Only seven (6%) of programs paid residents from practice plan dollars, while most (82%) were fully supported by federal GME funding. Nearly all four-year programs (97%) received full resident salary support from their institutions and 77% of programs accept residents with previous training. CONCLUSIONS: Nearly all EM programs are fully supported by their institutions, including the fourth postgraduate year. Most programs take residents with previous training. Although few programs have reduced their size, many are discussing this. Many programs have had difficulty with funding off-service rotations and many have had decreased numbers of off-service residents in their EDs. Recent GME funding changes have had adverse effects on EM residency programs.     

Residency training in physical medicine and rehabilitation. I: Clinical and didactic experience

A survey was conducted to determine the type of clinical and didactic training experience that was provided to resident trainees in physical medicine and rehabilitation (PM&R) in the 1987-1988 academic year. Chief residents from 43 (61%) of the 70 PM&R programs accredited by the Accreditation Council for Graduate Medical Education responded. According to respondents, the programs averaged 12.6 residents. The residents spent an average of 18.5 months on an inpatient bedservice, 12.6 months on outpatient exposures, and the remainder of the time attending other clinical experiences and didactic training. Forty percent of those responding reported that their programs required in-house call in postgraduate years (PGYs) 2 through 4, and 53% of the programs required no in-house call during the same clinical years. Seven percent of the programs required in-house call in PGYs 2 and 3, but none in PGY 4. The average time spent in electrodiagnostic studies was 7.6 months (range = 2 to 19 months). Electromyography exposure by completion of PGY 4 also varied widely, from 40 to 500 studies. Resident trainee exposure to inpatient and outpatient spinal cord injury, closed head injury, pediatric rehabilitation, sports medicine, and geriatric medicine, and rehabilitation fellowship positions being offered through the responding PM&R residency training programs were also surveyed. Some instances of apparent program imbalances or inadequate training which could reduce the scope of a resident's educational experience were noted.     

Assessment of musculoskeletal examination skills: physiatry residents as evaluators and models

OBJECTIVE: To evaluate the musculoskeletal examination (MSKE) skills of junior (postgraduate year [PGY] 2) physical medicine and rehabilitation (PM&R) residents and self-confidence with these skills, and to demonstrate changes in self-confidence in the MSKE skills of senior (PGY3 and PGY4) residents, who served as evaluators and models. DESIGN: Forty-one PGY2-4 residents participated in this retrospective cohort study, which was conducted within a residency program affiliated with two medical schools. Senior residents attended an instructional session in performing and evaluating MSKE skills, taught by a musculoskeletal physiatrist. The following week, junior residents were tested on their MSKE skills; nine seniors served as models, and another nine served as evaluators. Six seniors attended the instructional session only and did not participate in the evaluation. Juniors received a posttest teaching session on MSKE skills, before an unannounced repeat evaluation 5 mos later. All residents completed a survey regarding self-confidence in MSKE skills pre- and posttest teaching sessions. Performance of MSKE skills (based on PASSOR guidelines) and application of ACGME core competencies (medical knowledge, professionalism, interpersonal skills) were measured, and a survey was administered regarding self-confidence in MSKE skills. RESULTS: Posttest results showed a significant improvement of MSKE skills among juniors in the shoulder, lumbar spine, and knee examinations (P < 0.008), with the most robust improvement in the shoulder exam (P < 0.0001). Self-confidence of juniors in their MSKE skills increased significantly (P < 0.005). There was significant improvement (P < 0.008) in self-confidence in the MSKE skills of seniors who served as models and evaluators, but not in those who only attended the instructional session (P = 0.06). CONCLUSIONS: This evaluation and instructional method resulted in a significant improvement of MSKE skills of junior residents on formal testing. Using senior residents as evaluators and models improved their confidence in their own MSKE skills.     

Substance Use and Alcohol Abuse in Emergency Medicine Training Programs, by Resident Report

ABSTRACT
Objective : To determine the prevalence of substance use and alcohol abuse among emergency medicine residents.
Method : The study instrument was an anonymous, self-report survey that assessed the use of 13 substances and included the CAGE questions for measuring alcohol abuse. The survey was administered to emergency medicine residents at the time of the American Board of Emergency Medicine's annual In-Service Examination.
Results : Alcohol was the substance most commonly used by emergency medicine residents for nonmedical reasons. Using the CAGE score, 4.9% of residents were classified as alcoholic and another 7.6% as suspect for alcoholism, rates similar to those for housestaff of all specialties as reported in earlier studies. Instruction related to physician impairment during training in their emergency medicine residency was reported by only 36% of the respondents.
Conclusions : Emergency medicine residents report a low rate of illicit substance use and do not appear to misuse alcohol differently than other housestaff. Interpretation of these results must be tempered with the potential for underreporting that may occur with a voluntary self-report survey of a sensitive nature.
Acad. Emerg. Med. 1994; 1:47–53.     

Validity and reliability testing of the Oulu patient classification: instrument within primary health care for the older people

Aim.  The aim of the study was to evaluate the reliability and validity of The Oulu Patient Classification (OPC) instrument to see whether the instrument that has been developed for hospital care is valid and useful within primary health care for older people.
Background.  Although different patient classification instruments have been under development since the 1960s, this is still a very important research area today.
Method.  Inter-rater reliability testing of the OPC instrument was undertaken. The inter-rater reliability was tested through parallel classification ( n  = 1722). Validity testing was conducted as an expert validation of the manual for the OPC instrument, using a questionnaire during June and July of 2005 ( n  = 61).
Results.  The inter-rater reliability testing achieved over 70% consensus, Cohen's Kappa showed a strong consensus for OPC classifications (0.65). The reliability measured with Cronbach's Alpha was also acceptable.
Conclusion.  The results show that the OPC instrument provides a good overview of the patient's care needs and is a reliable instrument within primary health care for older people.     

Prospective Evaluation of Emergency Medicine Instruction for Rotating First–postgraduate–year Residents

Objective: To determine whether either bedside teaching alone (group A) or bedside teaching with written course materials (group B) improved written examination scores, satisfaction with the rotation, or clinical grades of rotating PGY1 residents.
Methods: A prospective, controlled educational trial was conducted. Sixty–five PGY1 residents from diverse specialties rotated in the ED for one month over a ten–month study period, and were included in the study. The PGY1 residents were assigned to group by month of rotation. All the PGY1 residents received unstructured bedside teaching by emergency medicine (EM) residents and faculty. In addition, group B received written course materials on day 1.
Results: Mean posttest scores were higher than mean pretest scores for the interns considered as a whole (p < 0.0001), but mean pretest, posttest, and clinical grades were comparable across instructional groups. Mean satisfaction ratings were higher for group A than for group B (p < 0.015). The interns specializing in EM achieved higher mean test scores (p < 0.013) and clinical grades (p < 0.003) than did the interns specializing in another medical specialty.
Conclusion: Both instructional methods were associated with improved written test performance. Written course materials did not augment bedside teaching in terms of test scores, clinical grades, or satisfaction. with the rotation. At a university–based, high–volume ED, bedside teaching offers educational benefit to rotating PGY1 residents that may not be augmented by written course materials.     

Emergency Medicine Resident Interpretation of Pediatric Radiographs

Objective: To examine the concordance of pediatric radiograph interpretation between emergency medicine residents (EMRs) and radiologists.
Methods: A prospective, observational study was performed in a university pediatric ED with an annual census of 60,000 visits. Radiographs ordered by EMRs from December 1993 through October 1994 were initially interpreted solely by the EMR, with subsequent unmasked final review by attending radiology staff. Misinterpreted radiographs were placed into 3 categories. The groupings included overreads , underreads with no change in treatment, and underreads that required a change in treatment.
Results: A total of 415 radiographs were interpreted by PGY1–3 residents. Overall concordance was found for 371 radiographs (89.4%). There were 44 misinterpretations (10.6%), with 24 (5.78%) overreads, 13 (3.13%) underreads, and 7 (1.69%) underreads that required follow-up interventions. Misinterpretations were similar for the different levels of training:

The 5 most frequently ordered radiographs were chest (28%), ankle (7%), foot (6%), wrist (5%), and hand (5%). The most frequently misinterpreted radiographs were sinus, foot, shoulder, facial, and hand.
Conclusion: 89.4% of all the radiographs interpreted by PGY1–3 residents were read correctly. Only 1.69% of the misinterpreted radiographs led to a change in management. Level of training did not significantly correlate with radiograph misinterpretation rates.     

Informed Consent for Research: Current Practices in Academic Emergency Medicine

Background:  The emergency department (ED) environment presents unique barriers to the process of obtaining informed consent for research.
Objectives:  The objective was to identify commonalities and differences in informed consent practices for research employed in academic EDs.
Methods:  Between July 1, 2006, and June 30, 2007, an online survey was sent to the research directors of 142 academic emergency medicine (EM) residency training programs identified through the Accreditation Council for Graduate Medical Education (ACGME).
Results:  Seventy-one (50%) responded. The average number of simultaneous clinical ED-based research projects reported was 7.3 (95% confidence interval [CI] = 5.53 to 9.07). Almost half (49.3%) of respondents reported that EM residents are responsible for obtaining consent. Twenty-nine (41.4%) participating institutions do not require documentation of an individual resident's knowledge of the specific research protocol and consent procedure before he or she is allowed to obtain consent from research subjects.
Conclusions:  It is common practice in academic EDs for clinical investigators to rely on on-duty health care personnel to obtain research informed consent from potential research subjects. This practice raises questions regarding the sufficiency of the information received by research subjects, and further study is needed to determine the compliance of this consent process with federal guidelines.     

Effect of time of admission on compliance with deep vein thrombosis prophylaxis in a tertiary medical intensive care unit

Summary.  Objective : We sought to evaluate deep vein thrombosis (DVT) prophylaxis compliance according to time of admission in a medical intensive care unit (MICU). Methods : This was a retrospective cohort study at a closed tertiary MICU. We classified patients into three groups (week days, weekends, and week nights), according to time of admission. An unweighted risk factor score (RFS) was calculated from 20 known risk factors. We defined DVT prophylaxis compliance as any type of prophylaxis (mechanical or pharmacologic) for RFS ≤ 3 or both types of prophylaxis for RFS > 3. Non-compliance was defined as no prophylaxis or single-type prophylaxis for RFS > 3. Results : We analyzed 105 admissions. Eighty (76.19%) patients received compliant DVT prophylaxis, and 25 (23.81%) patients received non-compliant regimens of whom 11 (10.48%) were not on any prophylaxis. DVT prophylaxis compliance was not different across the three admission groups. The non-compliant DVT prophylaxis group had a higher RFS (3.48 ± 2.1 vs. 2.25 ± 1.5; P  = 0.011), a trend towards fewer female patients (40% vs. 60%; P =  0.079), and a higher percentage of admissions by interns at the first postgraduate year (PGY) level (28% vs. 5.4%; P =  0.01). Logistic regression revealed that only RFS and PGY level were independent predictors for compliance ( P =  0.015 and 0.005 respectively). Time of admission was not a significant factor. Conclusions : Time of admission did not influence DVT prophylaxis compliance. Compliance improved with higher PGY level and lower RFS. A higher level of knowledge probably explains the association with PGY level; however, we cannot explain the inverse relationship between RFS and compliance.     

Moral distress questionnaire for clinical nurses: instrument development

Title.  Moral distress questionnaire for clinical nurses: instrument development.
Aim.  This paper is a report of a study to develop and test the psychometric properties of a culture-sensitive moral distress questionnaire among nurses employed in a variety of work settings.
Background.  In the course of the last decade, there has been increased interest in capturing healthcare professionals' experiences of stress associated with ethical dilemmas. Ethical issues emerge in grey areas and are often blurred, and have thus received insufficient attention.
Method.  The study comprised two phases: a qualitative phase to elicit the culture-specific themes and a quantitative phase, comprising the design of a 15-item questionnaire. The questionnaire was then completed by a convenience sample of 179 nurses from a variety of work settings. The data were collected in 2006.
Results.  Factor analysis resulted in three factors representing moral distress: (1) problems caused by work relationships among staff; (2) problems due to lack of resources; and (3) problems caused by time pressure. With regard to the construct validity of the questionnaire, differences between community and hospital nurses were tested, and a statistically significant difference was found between them in two among the three factors (relationships and time). The stability of the measures was examined by test-retest reliability and revealed statistically significant results.
Conclusions.  The instrument exhibits acceptable reliability and validity in the Israeli cultural context. Further research is needed to evaluate the measure in other cultural settings.     

A Longitudinal Study of Emergency Medicine Residents' Malpractice Fear and Defensive Medicine

Objectives: To determine the baseline level and evolution of defensive medicine and malpractice concern (MC) of emergency medicine (EM) residents.
Methods: Using a validated instrument consisting of case scenarios and Likert-type scale questions, the authors performed a prospective, longitudinal (June 2001 to June 2005) study of EM residents at five 4-year California residency programs.
Results: All 51 EM interns of these residencies were evaluated; four residents left their programs and one took medical leave, resulting in 46 graduating residents evaluated. MC did not affect the residency choice of interns. Although perceived likelihood of serious disease increased in case scenarios over time, defensive medicine decreased in 27% of cases and increased in 20%. On a scale with 1 representing extremely influential and 5 representing not at all influential, the mean (±SD) influence of MC on interns' and graduates' case evaluation and management was 2.5 (±1.1) and 2.7 (±1.0), respectively. Comparing interns and graduates, there was no significant difference in the percentages of respondents who declared MC (mean difference in proportions, 3.3%; 95% CI =−8.4% to 15%) or refused procedures because of MC (11.5%; 95% CI =−1.3% to 24.3%). More interns, however, declared substantial loss of enjoyment of medicine than graduates (48%; 95% CI = 30.3% to 65.5%).
Conclusions: Physicians enter four-year EM residencies in California with moderate MC and defensive medicine, which do not change significantly over time and do not markedly impact their decisions to perform emergency department procedures. Malpractice fear markedly decreases interns' enjoyment of medicine, but this effect decreases by residency completion.