University and Community Hospital Medical Student Emergency Medicine Clerkship Experiences

Objective : To determine whether there is a significant difference between educational opportunities for fourth-year medical students rotating at a university hospital (UH) compared with several community hospitals (CHs) during a mandatory emergency medicine (EM) clerkship.
Methods : A self-reported clinical tool was completed in real time by each student rotating for 2 weeks at the UH and 2 weeks at 1 of 4 CHs (3 affiliated and 1 unaffiliated). Students are required to document the number of patients seen and the number of procedures performed on each of 20 six-hour shifts. They rated the EM attending clinical teaching by site using a 5-point scale at the end of the clerkship.
Results : Most (95%) of the 87 students in the 7 clerkship blocks of the 1996–97 academic year rotated at the UH and a CH. Most (71%) students rated both the UH and the CH for the quality of teaching by attendings. There was a significant difference in the mean number of patients evaluated/shift (2.2 ± 0.10 vs 2.8 ± 0.10, UH vs CH; p < 0.001) and the mean number of procedures performed/shift (0.36 ± 0.04 vs 0.56 ± 0.05, UH vs CH; p < 0.001). Attending clinical teaching scores were significantly higher (p = 0.03) at the CHs.
Conclusions : The educational opportunities for students in an EM clerkship to evaluate patients and perform procedures were significantly greater at the community hospitals. Inclusion of community hospital settings in a medical student EM clerkship may optimize the clinical experience.     

Creation and Implementation of a National Emergency Medicine Fourth-Year Student Examination

Background

A National Board of Medical Examiners examination does not exist for Emergency Medicine (EM) students. To fill this void, the Clerkship Directors in Emergency Medicine tasked a committee with development of an examination for 4th-year (M4) EM students, based on a published syllabus, and consisting of questions written according to published question-writing guidelines.

Study Objectives

Describe examination development and statistics at 9 months.

Methods

The committee reviewed an existing EM student question database at www.saemtests.org for statistical performance, compliance with item-writing guidelines, and topic inclusion within the published EM M4 syllabus. For syllabus topics without existing questions, committee members wrote new items. LXR 6.0 software (Applied Measurement Professionals, Inc., Georgetown, SC) was used for examination administration. Data gathered included numbers of examinations completed, mean scores with SD, and point biserial correlation (rpb).

Results

Of the 553 questions assessed, 157 questions met the stated criteria, and 37 were included in the examination. Thirteen new questions were written by committee members to cover all curriculum topics. The National EM M4 Examination was released online August 1, 2011. Nine months later, the examination had been completed 1642 times by students from 27 clerkships. Mean score was 79.69% (SD 3.89). Individual question difficulties ranged from 26% to 99%. Question rpbs ranged from 0.067 to 0.353, mean 0.213 (SD 0.066).

Conclusions

A national group of EM educators developed an examination to assess a published clerkship syllabus. The examination contains questions written according to published item-writing guidelines, and exhibits content validity, appropriate difficulty levels, and adequate question discriminatory ability.     

Medical Student Leadership in Emergency Medicine

Emergency medicine is a profession that requires good leadership skills. Emergency physicians must be able to instill confidence in both the staff and patients, inspire the best in others, have the enthusiasm to take on a surplus of responsibilities, and maintain calmness during unexpected circumstances. Accordingly, residency program directors look carefully for leadership qualities and potential among their applicants. Although some people do have a predisposition to lead, leadership can be both learned and taught. In this article, we provide medical students with the tools that will help them acquire those qualities and thus make them more desirable by program directors.     

The 3-Minute Emergency Medicine Medical Student Presentation: A Variation on a Theme

Oral presentations are a critical element in the communication of medical knowledge between students and faculty, but in most locations, the amount of time spent on teaching the oral presentation is minimal. Furthermore, the standard oral presentation does not work well within the emergency medicine (EM) setting, due to time constraints and the different principles that make EM a unique specialty. This article provides a suggested approach on how to educate students on optimal oral presentations in EM, as well as providing a link to an online guide instructing medical students how to give oral presentations.     

Emergency Medicine Interest Group Curriculum: Faculty and Preclinical Student Opinions Differ in a Formal Needs Assessment

Background: Medical students and Emergency medicine (EM) faculty may have differing opinions on the ideal curriculum during the preclinical years. Objectives: To assess the perceived needs of preclinical medical students exploring EM and compare them with those of EM faculty regarding appropriate educational interventions. Methods: A survey instrument listing 15 workshops related to EM was administered to preclinical medical students in our Emergency Medicine Interest Group (EMIG), and to EM faculty. Respondents graded the perceived utility of each workshop offered at our medical school and those identified via a web search for EMIG. No recommendations for EMIG curriculum were identified through PubMed. Fisher's exact tests were computed using SPSS (SPSS Inc., Chicago, IL) with α = 0.05. Results: There were 48 medical students and 15 faculty members who completed the survey. Students strongly desired workshops in suturing (48/48; 100%), splinting (47/48; 97.9%), and basic electrocardiogram (ECG) interpretation (47/48; 97.9%). Least desired topics were history of EM (16/48; 33.3%), getting involved in EM organizations (20/48; 41.7%), and wellness (21/48; 43.8%). Women chose the domestic violence workshop more than men (p = 0.036). Faculty strongly supported workshops in conducting focused history and physical examination (14/15; 93.3%), the specialty of EM (14/15; 93.3%), and basic ECG interpretation (12/15; 80.0%). The lowest rated faculty preferences were ultrasound (5/15; 33.3%), history of EM (7/15; 46.7%), and emergency radiology (7/15; 46.7%). Conclusions: Preclinical students and faculty opinions of important educational workshops differed. Faculty favored the approach to the undifferentiated patient and an introduction to the specialty, whereas students preferred hands-on workshops. Both groups agreed that basic ECG interpretation was useful. These data may be useful for designing an educational program that is interesting to preclinical students while still meeting the needs as perceived by medical student educators.     

Faculty Prediction of In-training Examination Scores of Emergency Medicine Residents

Background

The Emergency Medicine In-Training Examination (EMITE) is one of the only valid tools for medical knowledge assessment in current use by emergency medicine (EM) residencies. However, EMITE results return late in the academic year, providing little time to institute potential remediation.

Objective

The goal of this study was to determine the ability of EM faculty to accurately predict resident EMITE scores prior to results return.

Methods

We asked EM faculty at the study site to predict the 2012 EMITE scores of the 50 EM residents 2 weeks prior to results being available. The primary outcome was prediction accuracy, defined as the proportion of predictions within 6% of the actual score. The secondary outcome was prediction precision, defined as the mean deviation of predictions from the actual scores. We assessed several faculty background variables, including years of experience, educational leadership status, and clinical hours worked, for correlation with the two outcomes.

Results

Thirty-two of the 38 faculty (84.2%, 95% confidence interval [CI] 69.6–92.6) participated in the study, rendering a total of 1600 predictions for 50 residents. Mean resident EMITE score was 81.1% (95% CI 79.5–82.8%). Mean prediction accuracy for all faculty participants was 69% (95% CI 65.9–72.1%). Mean prediction precision was 5.2% (95% CI 4.9–5.5%). Education leadership status was the only background variable correlated with the primary and secondary outcomes (Spearman's ρ = 0.51 and −0.53, respectively).

Conclusion

Faculty possess only moderate accuracy at predicting resident EMITE scores. We recommend a multicenter study to evaluate the generalizability of the present results.     

The Effect of Resident Duty-Hours Restrictions on Internal Medicine Clerkship Experiences: Surveys of Medical Students and Clerkship Directors

Phenomenon: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students’ and clerkship directors’ perceptions of the effects of the 2011 DHR on internal medicine clerkship students’ experiences with teaching, feedback and evaluation, and patient care. Approach: Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation. Findings: Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. Insights: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student–patient relationship and students’ clinical skills acquisition.     

Advanced Opportunities for Student Education in Emergency Medicine

Many medical students are excited about emergency medicine (EM) following a standard clerkship and seek out additional learning opportunities. An advanced EM elective may accomplish several educational goals, including development of clinical skills in evaluating the undifferentiated patient, broader exploration of the field of EM, and more focused study of one particular aspect of EM. Previously cited examples include pediatric EM, medical toxicology, occupational medicine, sports medicine, and EM research. Numerous other EM specialty courses for senior medical students are emerging, as reflected in the “Undergraduate Rotations” listings on the Society for Academic Emergency Medicine. A few examples drawn from the list include emergency ultrasound, international EM, wilderness medicine, disaster medicine, geriatric EM, and hyperbaric medicine. Educators aspiring to develop, or in the process of developing, an advanced EM elective may benefit from a brief overview of necessary course considerations, including didactic format, the clinical role of the medical student in the emergency department, and involvement with patient procedures. Suggestions are made regarding additional educational opportunities, including follow‐up of patients seen in the emergency department and development of an emergency department radiology case file. This article also addresses several related concerns, including suggested prerequisites, administration and cost considerations, appropriate didactic topics, and methods for evaluating students. Several EM subspecialty areas, namely pediatric EM, medical toxicology, and out‐of‐hospital care, are specifically discussed. Formal advanced cardiac life support training is also often included in an advanced EM elective and is briefly discussed. The overall intent of this article is to provide medical student educators with resources and ideas to assist them in developing a unique advanced EM elective.     

A Survey of Nonphysician Medical Screening Examinations in Academic Emergency Medicine

OBJECTIVES: To determine the proportions of U.S. emergency medicine (EM) residency programs that use nonphysicians to perform medical screening examinations (MSEs) in lieu of a physician evaluation. METHODS: This was a cross-sectional observational study consisting of a mail survey of the 109 base hospitals of accredited U.S. EM residency programs. Follow-up letters were sent twice to nonrespondents. Questions regarding ED demographics, the performance and structure of MSEs by physicians and nonphysicians, and the exact nature and purpose of such examinations were included. RESULTS: Ninety of 109 (83%) programs responded. Eighty-seven of the 90 programs (97%) perform MSEs on all patients presenting to the ED prior to discharge. Thirty-seven percent (33/90) perform nonphysician MSEs (NPMSEs) at least some of the time. Fifty percent (16/32) refer patients to an outside facility based on the result of the screening, and in 32% of cases the patient is not offered the choice of an ED evaluation. Seventy percent (19/27) at times refer patients, including uninsured patients, to a same-day clinic within their hospital system. Seven of 27 (26%) programs performing NPMSEs reported occasional adverse events, defined as two to 11 per year. Eight of 22 (36%) reported poorer clinical outcomes than expected from ED care as a result of the NPMSE, and 18 of 25 (72%) reported some degree of patient dissatisfaction. Two programs reported death as a result of NPMSEs. CONCLUSIONS: The use of NPMSEs is common and is frequently used as a basis for referring patients away from the ED without a physician examination. Using NPMSEs may be associated with adverse events, including patient dissatisfaction, morbidity, and possibly, mortality.     

Medical Student Career Advice Related to Emergency Medicine

Objective: To describe the advisors and the advice given to residency candidate interviewees interested in specializing in emergency medicine (EM).
Methods: All interviewees at a university-based EM residency program were surveyed. Data were collected anonymously and included demographic information, characteristics of each applicant's medical school, career advice by non-EM faculty, and access to advisors who are residency-trained in and practicing EM.
Results: Of 114 interviewees, 104 (91%) completed the survey. Only 45% of the respondents reported they were assigned an emergency physician (EP) advisor by their school, and 38% sought advice informally from an EP. Of those students receiving advice from an EP, 70% reported their advisor was residency-trained in EM. Most (57%) respondents reported receiving negative advice concerning a career in EM from non-EM medical school faculty. Of the 59 students reporting negative advice, 18 (31%) received negative comments from non-EM residency program directors, 23 (39%) from non-EM department chairs, and 4 (7%) from medical school deans. The presence of a residency training program increased the chances of a student's being assigned an EP advisor, but neither an EP advisor nor the departmental status of EM within the students' institutions was associated with receipt of negative advice.
Conclusions: Students considering specializing in EM often receive negative advice or have no assigned EP advisor. These factors may adversely affect entry into the field of EM.     

Reliability of Faculty Clinical Evaluations of Non-Emergency Medicine Residents during Emergency Department Rotations

Objectives: To assess the reliability of faculty evaluations of non-emergency medicine (non-EM) residents during clinical ED rotations and to determine the effect that the “leniency” of grading by these evaluators had on the residents' final evaluations. Methods: A prospective, observational study of the evaluation patterns of EM faculty was performed in an academic ED (50, 000 visits yearly census). Each resident was evaluated on a daily basis by a board-certified or board-prepared emergency physician. The evaluation form rated 7 characteristics, but only the rating for overall clinical competence was used for data analysis. If an attending evaluated the same resident more than once, only the first evaluation was used to avoid bias from prior exposure. The scoring patterns of the evaluators, both individually and in groups, were analyzed using 1-way analysis of variance. Evaluator leniency was estimated using the mean evaluator score across all residents. Since each resident was evaluated by a different combination of evaluators, evaluator leniency for each resident was estimated from the mean leniency of the evaluators who specifically assessed that resident. Results: During the period of the study, 66 residents rotated through the ED, yielding a total of 401 evaluations. When the scoring patterns of individual evaluators were analyzed, a high degree of variability was found in the mean scores (range 5.23–8.09) and SDs (range 0.45–1.55) across evaluators; p = 0.0001. There was a moderate correlation between the mean overall competence score received by each resident and that resident's evaluators' leniency, r = 0.52; p = 0.0001. Conclusions: There is significant variability in the scoring patterns of individual evaluators. The evaluators in this study showed large variations in both leniency (as measured by their mean score) and range restriction (as measured by their SD). The differences in evaluator scoring leniency have a moderate correlation with the overall score received by the resident.     

An Educator''s Guide to Teaching Emergency Medicine to Medical Students

There is a need for every medical school graduate to handle emergencies as they arise in the daily practice of medicine. Emergency medicine (EM) educators are in a unique position to provide students with basic life support skills, guidance in assessing the undifferentiated patient, and exposure to the specialty of EM during all years of medical school. Emergency physicians can become involved in a variety of education experiences that can supplement the preclinical curriculum and provide access to our specialty at an early stage. A well-designed course in the senior year allows students to develop critical thinking and patient management skills that are necessary for any medical career path. It can ensure that all medical students are exposed to the skills essential for evaluating and stabilizing the acutely ill patient. To implement this type of course, learning objectives and evaluation methods must be set when the curriculum is developed. An effective course combines didactic and clinical components that draw on the strengths of the teaching institution and faculty of the department. A structured clerkship orientation session and system for feedback to students are essential in nurturing the development of student learners. This article provides an approach to assist the medical student clerkship director in planning and implementing EM education experiences for students at all levels of training, with an emphasis on the senior-year rotation.     

Developing a Standardized Faculty Evaluation in an Emergency Medicine Residency

Background: Quality educators are a core component of successful residency training. A structured, consistent, validated evaluation of clinical educators is important to improve teaching aptitude, further faculty development, and improve patient care. Study Objectives: The authors sought to identify specific domains of instructional quality and to develop a composite instrument for assessing instructional quality. Methods: The study setting is a 3-year residency program. Residents rated the quality of faculty member instruction using an 18-item survey twice over a 2-year period (2004–2005). Each survey item used a 9-point scale. Factor analysis employing a Varimax rotation identified domains of instructional performance. Cronbach's alpha was used to assess the internal consistency of the identified domains. Results: There were 29 faculty members evaluated. Using 2004 data, five domains of instructional quality were identified that explained 92.5% of the variation in survey responses (χ² = 2.33, P = 0.11). These were: Competency and Professionalism (30% of variation), Commitment to Knowledge and Instruction (23%), Inclusion and Interaction (17%), Patient Focus (13%), and Openness to Ideas (9%). Competency and Professionalism included appropriate care, effective patient communication, use of new techniques, and ethical principles. Commitment to Knowledge and Instruction included research, mentoring, feedback, and availability. Inclusion and Interaction included procedural participation and bedside teaching. Patient Focus included compassion, effective care, and sensitivity to diverse populations. Openness to Ideas included enthusiasm and receptivity of new ideas. These five domains were consistent in the 2005 data (Cronbach's alpha 0.68–0.75). Conclusions: A five-domain instrument consistently accounted for variations in faculty teaching performance as rated by resident physicians. This instrument may be useful for standardized assessment of instructional quality.