The Impact of Environmental Factors on Emergency Medicine Resident Career Choice

OBJECTIVE: To evaluate the impact of environmental factors on emergency medicine (EM) resident career choice. METHODS: Program directors of all U.S. EM residencies were surveyed in November 1997. A 22-item questionnaire assessed resources allocated to research, fellowship availability, academic productivity of faculty and residents, and career choices of residency graduates. RESULTS: The response rate was 83%. The program director (mean+/-SD) estimates of resident career choice were as follows: 27.8+/-19.1% pursued academic positions with emphasis on teaching, 5.4+/-9.8% pursued academic positions with emphasis on research, and 66.8+/-23.1%, pursued private practice positions. In addition, 5.70+/-6.13% of the residency graduates were estimated to seek fellowship training. Univariate analyses demonstrated that increasing departmental funding for research, having substantial resource availability (defined as having at least two of the following: dedicated laboratory space; support for a laboratory research technician/assistant, a clinical research nurse or study coordinator, a statistician, or an assistant with a PhD degree), a greater number of peer-reviewed publications by residents (r = 0.22; p = 0.08), and a greater number of peer-reviewed publications by faculty (r = 0.26; p = 0.04) positively correlated with the percentage of graduates who pursue academic research careers. Using multiple regression, however, increasing intramural funding and the presence of substantial resource availability were the only variables predictive of resident pursuit of an academic research career. CONCLUSION: Modification of the EM training environment may influence the career choices of graduates. Specifically, greater commitment of departmental funds and support of resources for research may enhance the likelihood of a trainee's choosing an academic research career.     

Academic Career Development for Emergency Medicine Residents: A Road Map

As the marketplace for academic positions in emergency medicine grows more competitive, it becomes increasingly important for residents who desire academic careers to distinguish themselves during their residency. This report attempts to outline a road map for department and residency program leaders to help their houseofficers become successful candidates for an academic emergency medicine position. Specific ways a resident can enhance his or her "academic marketability" include 1) involvement in research, 2) establishment of a track record of productivity via scholarly writing, 3) awareness of the literature in the specialty, 4) involvement in specialty organizations and hospital committees, 5) competition for national awards, 6) gaining education skills, 7) developing an academic niche, and 8) fellowship training.     

Evaluation of a Residency Program''s Experience with a One-week Emergency Medicine Resident Rotation at a Medical Liability Insurance Company

INTRODUCTION: The authors' residency program implemented a one-week rotation at the office of a medical liability insurance company. Residents examined 30 closed malpractice claims cases and sat in on settlement discussions. OBJECTIVE: To review the residents' evaluations of their experiences and to determine whether this was a worthwhile addition to the emergency medicine (EM) residency curriculum. METHODS: This was a five-year retrospective study that reviewed residents' annual evaluations from 1994 to 1999 regarding the medical liability rotation. A five-point scale was used to score specific categories in the rotation and an open-ended section was used to collect general comments. RESULTS: A total of 179 resident evaluations were reviewed. The quality of teaching ranked in the 80th percentile, the clinical caseload ranked in the 85th percentile, and level of responsibility ranked in the 79th percentile for all EM rotations. Specific comments included "All MDs should do this in their training"; "Quite an eye opener"; and "Good exposure to legal aspects of EM." CONCLUSIONS: Overall, EM residents found the one-week rotation to be invaluable and a good learning experience. This rotation ranked above average when compared with all of our other EM residency rotations.     

Effect of Changes in Graduate Medical Education Funding on Emergency Medicine Residency Programs

OBJECTIVE: To determine whether changes in graduate medical education (GME) funding have had an impact on emergency medicine (EM) residency training programs. METHODS: A 34-question survey was mailed to the program directors (PDs) of all 115 Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs in the United States in the fall of 1998, requesting information concerning the impact of changes in GME funding on various aspects of the EM training. The results were then compared with a similar unpublished survey conducted in the fall of 1996. RESULTS: One hundred one completed surveys were returned (88% response rate). Seventy-one (70%) of the responding EM residency programs were PGY-I through PGY-III, compared with 55 (61%) of the responding programs in 1996. The number of PGY-II through PGY-IV programs decreased from 25 (28%) of responding programs in 1996 to 17 (16%). The number of PGY-I through PGY-IV programs increased slightly (13 vs 10); the number of EM residency positions remained relatively stable. Fifteen programs projected an increase in their number of training positions in the next two years, while only three predicted a decrease. Of the respondents, 56 programs reported reductions in non-EM residency positions and 35 programs reported elimination of fellowship positions at their institutions. Only four of these were EM fellowships. Forty-six respondents reported a reduction in the number of non-EM residents rotating through their EDs, and of these, 11 programs reported this had a moderate to significant effect on their ability to adequately staff the ED with resident physicians. Sixteen programs limited resident recruitment to only those eligible for the full three years of GME funding. Eighty-seven EM programs reported no change in faculty size due to funding issues. Sixty-two programs reported no change in the total number of hours of faculty coverage in the ED, while 34 programs reported an increase. Three EM programs reported recommendations being made to close their residency programs in the near future. CONCLUSIONS: Changes in GME funding have not caused a decrease in the number of existing EM residency and fellowship training positions, but may have had an impact in other areas, including: an increase in the number of EM programs structured in a PGY-I through PGY-III format (with a corresponding decrease in the number of PGY-II through PGY-IV programs); a decrease in the number of non-EM residents rotating through the ED; restriction of resident applicants who are ineligible for full GME funding from consideration by some EM training programs; and an increase in the total number of faculty clinical hours without an increase in faculty size.     

Emergency Medicine Residency Applicant Educational Debt Relationship with Attitude toward Training and Moonlighting

OBJECTIVES: Heated debate persists regarding the role of resident moonlighting in emergency medicine (EM). The attitudes of EM residency applicants have not been assessed. The objectives of this study were to assess: 1) the level of educational debt among EM residency applicants, 2) their perception of increased risk potential to patients from unsupervised EM resident practice, and 3) their opposition to laws restricting moonlighting. The authors then report the relationship between the degree of indebtedness and these stated positions. METHODS: Fifty-four EM residency programs returned 393 responses to a 1996 anonymous survey. Applicants recorded: 1) their indebtedness, 2) whether they believed that EDs should hire only physicians who have completed full training in an EM residency, and 3) whether they believed that unsupervised EM practice prior to completing EM training carries a higher risk of adverse patient outcomes. The authors used a t-test and logistic regression to determine whether there was any significant difference in debt between responders who answered yes and those who answered no to the various questions. A p-value < 0.05 was considered significant. RESULTS: The mean +/- SD debt was $72,290 +/- 48,683 (median $70,000). Most EM applicants (84.8%) agreed that unsupervised medical care by EM residents carries a higher risk of adverse patient outcomes. Paradoxically, only half the applicants opposed a moonlighting ban. Responses did not statistically correlate with educational debt. CONCLUSIONS: Emergency medicine residency applicant debt is large. The EM applicants' opposition to laws that would restrict moonlighting was mixed. This was inconsistent with the majority acknowledging an increased risk potential to patients. Nearly all EM applicants would still select EM as a career, even if moonlighting were to be banned.     

Combined Residency Training in Emergency Medicine and Internal Medicine: An Update on Career Outcomes and Job Satisfaction

Objectives:  This study was designed to provide an update on the career outcomes and experiences of graduates of combined emergency medicine-internal medicine (EM-IM) residency programs.
Methods:  The graduates of the American Board of Emergency Medicine (ABEM) and American Board of Internal Medicine (ABIM)-accredited EM-IM residencies from 1998 to 2008 were contacted and asked to complete a survey concerning demographics, board certification, fellowships completed, practice setting, academic affiliation, and perceptions about EM-IM training and careers.
Results:  There were 127 respondents of a possible 163 total graduates for a response rate of 78%. Seventy graduates (55%) practice EM only, 47 graduates (37%) practice both EM and IM, and nine graduates (7%) practice IM or an IM subspecialty only. Thirty-one graduates (24%) pursued formal fellowship training in either EM or IM. Graduates spend the majority of their time practicing clinical EM in an urban (72%) and academic (60%) environment. Eighty-seven graduates (69%) spend at least 10% of their time in an academic setting. Most graduates (64%) believe it practical to practice both EM and IM. A total of 112 graduates (88%) would complete EM-IM training again.
Conclusions:  Dual training in EM-IM affords a great deal of career opportunities, particularly in academics and clinical practice, in a number of environments. Graduates hold their training in high esteem and would do it again if given the opportunity.     

Predictive Value of Letters of Recommendation vs Questionnaires for Emergency Medicine Resident Performance

Objective: To evaluate the predictive value of standard letters of recommendation (LORs) vs preprinted questionnaires (PPQs) for resident performance at one emergency medicine (EM) residency program.
Methods: A retrospective association of LORs and PPQs with intraining resident performance ratings was done at one EM residency program. The residency application files of EM residents who completed the program were reviewed to locate files that had LORs and PPQs written by the same author. Seventeen resident files contained 32 LOR/PPQ pairs. These LORs and PPQs were submitted in a blinded fashion to 3 outside EM residency directors. Each LOR and PPQ was evaluated for the applicant's suitability for the speciality of EM, medical knowledge, procedural skills, interpersonal skills, motivation, and overall rank. The scores given by the outside reviewers were compared with resident performance ratings determined by 5 EM attending physicians who evaluated the residents along the same 6 dimensional ratings.
Results: Statistically, no differences were found between the LORs and PPQs in predicting resident performance.
Conclusions: PPQs may substitute for LORs in the evaluation of resident applicants.     

General Competencies Are Intrinsic to Emergency Medicine Training: A Multicenter Study

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) has promulgated six areas called General Competencies (GCs) that residency programs are required to evaluate. The authors sought to determine if these domains were an intrinsic part of emergency medicine (EM) residency training by using a global assessment evaluation device. METHODS: This was an observational, multicenter, cross-sectional study that compared GC acquisition between first-, second-, and third-year (EM1, EM2, and EM3) residents. Five postgraduate year (PGY) 1 to PGY 3 allopathic EM programs in Michigan participated. A global assessment form using a 1 through 9 ordinal scale with 86 scoring items was given to program directors for each resident in their programs. Analysis of variance (ANOVA) was used to compare the means between EM1, EM2, and EM3 scores. RESULTS: Five EM programs evaluated 150 residents. The GC scores were as follows: Patient Care: EM1 4.92, EM2 5.79, and EM3 6.40; Medical Knowledge: EM1 4.90, EM2 5.80, and EM3 6.46; Practice-based Learning and Improvement: EM1 4.60, EM2 5.48, and EM3 6.16; Interpersonal and Communication Skills: EM1 4.99, EM2 5.39, and EM3 6.01; Professionalism: EM1 5.43, EM2 5.68, and EM3 6.27; Systems-based Practice: EM1 4.80, EM2 5.48, and EM3 6.21. ANOVA showed statistically significant differences (p < 0.001) for all GCs. CONCLUSIONS: EM residents from several residency programs showed statistically significant progressive acquisition of the ACGME GCs using a global assessment device. This suggests that the GCs may be an intrinsic component in the training of EM residents.     

First-postgraduate-year Resident Clinical Time Use on Three Specialty Rotations

OBJECTIVE: To compare in-hospital time uses by first-postgraduate-year (PGY1) residents during rotations in emergency medicine (EM), internal medicine (IM), and surgery (S). This article reports the clinical components of residency time use. METHODS: A cross-sectional, observational study of the clinical activities of EM PGY1 residents was performed while the residents were on duty during the three specialty rotations. The activities were recorded by an observer using a log with predetermined categories for clinical activities. A time-blocked, convenience sample of resident shifts was observed for each service rotation. The sample was proportional to the total number of hours for which a PGY1 resident was expected to be in the hospital during a rotation on that service. No attempt was made to sample the same resident at all time periods or on all rotations. Proportions were compared by chi2; alpha = 0.0001. RESULTS: Twelve PGY1 residents were observed for a total of 166 hours on S, 156 hours on IM, and 120 hours on EM. These hourly amounts were representative of a typical two-week span of service on each rotation for the residents. On average, the residents spent 57% of their time on clinical or service-oriented activities. During EM and IM rotations, the residents spent most of their time performing clinical information gathering and engaging in case management and data synthesis (52% of total clinical effort). Within this category, residents on EM were more involved with case discussion and review of ancillary test results than on IM (34% vs 20% of time in this category). Conversely, proportionately less time in this category was devoted to documentation on the EM vs IM rotation (56% vs 80%; p < 0.0001). The greatest opportunity to perform procedures was on the S rotation (31% of total clinical time vs 6% for other specialties; p < 0.0001). CONCLUSION: Awareness of the clinical activities performed on PGY1 rotations can help residency directors anticipate educational needs to balance their residents' experience. Since 29% and 42% of total clinical time on PGY1 EM and IM rotations, respectively, is focused on documentation, efforts to enhance charting skills and efficiency are warranted. Also, efforts to enhance PGY1 procedural experience outside of the S rotation appear warranted.     

四川大学华西医院2017年住院医师规范化培训结业考核结果分析

目的收集并分析四川大学华西医院2017年住院医师结业考核情况,以期为进一步实现住院医师培养同质化提供借鉴依据。方法收集四川大学华西医院2017年381名住院医师基本信息和结业考核成绩,采用χ^2检验按不同身份类型、不同学历层次对其理论考核、技能考核、整体通过情况进行比较。结果不同身份类型住院医师在理论考试(χ^2=1.3849,P=0.7091)、技能考试(χ^2=3.3631,P=0.3390)、总体考核(χ^2=4.2747,P=0.2333)及不同学历层次住院医师理论考试(χ^2=0.4175,P=0.8116)、技能考试(χ^2=0.4614,P=0.7940)、总体考核(χ^2=0.6800,P=0.7118)的差异均无统计学意义。结论四川大学华西医院住院医师培养已基本实现同质化产出的目标。     

An Assessment of the Faculty Development Needs of Junior Clinical Faculty in Emergency Medicine

Objectives: Academic physicians must be able to access the resources necessary to support their ongoing professional development and meet requirements for continued academic advancement. The authors sought to determine the self‐perceived career development needs of junior clinical faculty in emergency medicine (EM) and the availability of educational resources to meet those needs. Methods: An educational “needs assessment” survey was distributed to 954 American College of Emergency Physicians (ACEP) members listed in the ACEP database as being faculty at EM residency programs in the United States and having graduated from an EM residency within the past 7 years. Respondents were asked to rank the importance of 22 areas of faculty development to their own professional growth and then to indicate whether educational resources in each area were available to them. Respondents were also asked to note the educational formats they prefer. A search for currently available resources in each topic area was undertaken and compared to the survey results. Results: A total of 240 responses were received. Self‐perceived career development needs were identified in the following areas: bedside teaching, lecture development, business skills, managerial skills, educational research, mentorship and career counseling, interpersonal skills, leadership skills, scholarly writing skills, physician wellness, and knowledge of the faculty development process. While a review of currently available educational resources revealed lectures, conferences, and online materials pertinent to most of these topics, a relative lack of resources in the areas of mentorship and physician wellness was identified. Conclusions: Junior clinical faculty in EM perceive a lack of educational resources in a number of areas of faculty development. The academic community of EM should strive to improve awareness of and access to currently existing resources and to develop additional resources to address the area of physician wellness. The lack of mentorship in academic EM continues to be a problem in search of a solution. ACADEMIC EMERGENCY MEDICINE 2008; 15:1–5 © 2008 by the Society for Academic Emergency Medicine     

The Effects of the Absence of Emergency Medicine Residents in an Academic Emergency Department

Objective: What are the quality effects of an emergency medicine (EM) residency, and the associated 24/7 supervision of residents by faculty, in an academic emergency department (ED)? The authors evaluated activity and quality indicators when there were no EM residents present. The hypothesis of the study was that there was no difference between the patient care provided by faculty supervising EM residents and that with an alternative model without EM residents (AbsenceEMResident). Methods: To support the weekly residency educational program (Thursday), EM residents are not scheduled clinically for a 24‐hour period (ConfDay). Emergency medicine resident coverage (mean 62.7 hours) was replaced with incremental faculty and mid‐level providers (mean 41.0 hours). This study was limited to adult patients (22,527 visits of 39,190 ED total) for six months (January—June 2001) and compared indicators for ConfDay (n = 23) with all other days (NotConfDay, n = 158). Results: Comparing ConfDay (2,842 visits) with NotConfDay (19,685 visits), there was no difference in mean daily visits, inpatient admissions, intensive care unit admissions, or emergency medical services arrivals. ConfDay decision‐to‐admit time (333 vs. 313 min, p = 0.03) and length of stay for admissions (490 vs. 445 min, p = 0.000) were longer, with no difference for treat/release patients. There was no difference in the numbers of laboratory or radiology tests, consultations, unscheduled return visits, or patient satisfaction. Conclusion: During the study period, there was no measurable difference for most of the quality indicators studied. The AbsenceEMResident model is less efficient in admitting patients. Faculty supervision results in the same number of laboratory and radiology tests and consultations. Other specialties may consider this model if off‐hours care becomes a concern.     

Recent Trends in Primary Care Interest and Career Choices Among Medical Students at an Academic Medical Institution

Phenomenon: As an impending shortage of primary care physicians is expected, understanding career trajectories of medical students will be useful in supporting interest in primary care fields and careers. The authors sought to characterize recent trends in primary care interest and career trajectories among medical students at an academic medical institution that did not have a family medicine department. Approach: Match data for 2,477 graduates who matched into resident training programs between 1989 and 2014 were analyzed to determine the proportion entering primary care residency programs. An online search and confirmatory phone call methodology was used to determine primary care career trajectories for the 795 graduates who matched into primary care residency programs between 1989 to 2010. Subanalyses were performed to characterize primary care career entrance among graduates who matched into the three primary care residency programs: Family Medicine, Categorical and Primary Care Internal Medicine, and Categorical and Primary Care Pediatrics. Findings: Between 1989 and 2014, 911 (37%) of all matched graduates matched into primary care residency programs. Of the 795 graduates who matched into these programs between 1989 and 2010, less than half (245; 31%) entered primary care careers. Of the graduates who ultimately entered primary care careers, 82% matched into either internal medicine or pediatrics residency programs and 18% matched into family medicine programs. Although there have been fluctuations in primary care interest that seem to parallel health care trends over the 26-year period, the overall percentage of graduates entering primary care residency programs and careers has remained fairly stable. Between 2006 and 2010, entrance into both primary care residency programs and primary care careers steadily increased. Despite this, the overall percentage of matched graduates who entered primary care careers over the 22-year study period (12%) was less than the national average (16%–18%). Insights: In the 26-year period between 1989 and 2014, primary care career interest increased slightly among medical students at this academic medical institution, with fluctuations that seem to coincide with national health care trends. Year-to-year fluctuations appear to be driven by rising numbers of Categorical Pediatrics and Categorical Internal Medicine matchers pursuing careers in primary care. There may be a need for specialized curricula and strategies to promote and retain interest in primary care at academic medical institutions, especially at institutions without family medicine training programs.     

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.