Physical Diagnosis Skills of Physicians in Training: A Focused Assessment

Objective: To assess the proficiency of emergency medicine (EM) trainees in the recognition of physical findings pertinent to the care of the critically ill patient.
Methods: Fourteen medical students, 63 internal medicine (IM) residents, and 47 EM residents from three university-affiliated programs in Philadelphia were tested. Proficiency in physical diagnosis was assessed by a multimedia questionnaire targeting findings useful in emergencies or related to diseases frequently encountered in the ED. Attitudes toward diagnosis not based on technology, teaching practices of physical examination during EM training, and self-motivated learning of physical diagnosis also were assessed for all the EM trainees.
Results: With the exception of ophthalmology, the EM trainees were never significantly better than the senior students or the IM residents. They were less proficient than the IM residents in cardiology, and not significantly different from the IM residents in all other areas. For no organ system tested, however, did they achieve less than a 42.9% error rate (range: 42.9–72.3%, median = 54.8%). There was no significant improvement in proficiency over the three years of customary EM training. The EM residents who had received supervised teaching in physical diagnosis during training achieved a significantly higher cumulative score. The EM residents attributed great clinical importance to physical diagnosis and wished for more time devoted to its teaching.
Conclusions: These data confirm the recently reported deficiencies of physical diagnosis skills among physicians in training. The results are particularly disturbing because they relate to EM trainees and concern skills useful in the ED. Physical diagnosis should gain more attention in both medical schools and residency programs.     

The Performance of Procedures on the Recently Deceased

OBJECTIVE: To determine the prevalence of performing procedures on the recently deceased for training purposes in emergency departments (EDs) with emergency medicine (EM) training programs. METHODS: Surveys were mailed to program directors of Accreditation Council for Graduate Medical Education (ACGME)-approved residency programs in EM. A check-off system was used to identify which procedures were performed and who performed the procedure. The survey also documented whether consent was obtained and whether written policies exist that address this issue. A Likert scale was used to evaluate respondents' attitudes toward this practice. RESULTS: Ninety-six (83%) of 116 surveys were returned. Forty-seven percent of the respondents indicated procedures were performed on the recently deceased for teaching purposes in their EDs. Emergency medicine residents perform the procedures in all departments where this practice occurs, with off-service residents and medical students using this technique in half of those departments. Paramedics, flight nurses, and attending physicians occasionally use this resource. Endotracheal intubation was the most commonly performed procedure. Seventy-six percent stated they "almost never" obtain consent from family members. Only four of 96 respondents have written policies concerning this practice. The majority of program directors (69%) would favor a position statement from a national EM organization concerning this issue, while 11% were opposed. CONCLUSIONS: The performance of procedures on the recently deceased is a common and important practice in EM training programs. Consent is infrequently obtained and policies concerning this practice are rare and restrictive when present.     

Injuries to emergency medicine residents on ems rotations

Objectives. To study the incidence and nature of injuries sustained by emergency medicine (EM) residents during EMS rotations, and steps taken at EM residency programs to increase resident safety during field activities. Methods. An eight-question survey form was mailed to all 114 U.S. EM residency directors, with a second mailing to nonresponders eight weeks after the initial mailing. Results. A total of 105 surveys were returned (92%). Six surveys were from new programs whose residents have not yet rotated on EMS. These were excluded from further analysis, leaving 99 programs. Of these, 91 (92%) reported no injuries. One EM resident died in a helicopter crash in 1985. Seven other injury events were reported: 1) facial lacerations, rib fractures, and a shoulder injury in an ambulance accident; 2) an open finger fracture (crushed by a backboard); 3) contusions and a concussion when an ambulance was struck by a fire engine; 4) a groin pull sustained while entering a helicopter; 5) bilateral metatarsal fractures in a fall; 6) rib fractures, a pneumothorax, and a concussion in an ambulance accident; and 7) “minor injuries” sustained in a crash while responding to a scene in a program-owned response vehicle. Actions taken at residency programs to reduce the risk of injury include the use of ballistic vests (four programs), requiring helmets on flights (five programs), and changing flight experience from mandatory to optional (two programs). Ten programs (10%) reported using ground scene safety lectures, and nine programs (15% of those offering flights) reported various types of flight safety instruction. Sixty-nine programs (70%) reported no formal field safety training or other active steps to increase resident safety on EMS rotations. Conclusions. Injuries sustained by EM residents during EMS rotations are uncommon but nontrivial, with several serious injuries and one fatality reported. The majority of EM residency programs have no formal safety training programs for EMS rotations.     

The Status of Bedside Ultrasonography Training in Emergency Medicine Residency Programs

Bedside ultrasonography (BU) is rapidly being incorporated into emergency medicine (EM) training programs and clinical practice. In the past decade, several organizations in EM have issued position statements on the use of this technology. Program training content is currently driven by the recently published "Model of the Clinical Practice of Emergency Medicine," which includes BU as a necessary skill. OBJECTIVE: The authors sought to determine the current status of BU training in EM residency programs. METHODS: A survey was mailed in early 2001 to all 122 Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs. The survey instrument asked whether BU was currently being taught, how much didactic and hands-on training time was incorporated into the curriculum, and what specialty representation was present in the faculty instructors. In addition, questions concerning the type of tests performed, the number considered necessary for competency, the role of BU in clinical decision making, and the type of quality assurance program were included in the survey. RESULTS: A total of 96 out of 122 surveys were completed (response rate of 79%). Ninety-one EM programs (95% of respondents) reported they teach BU, either clinically and/or didactically, as part of their formal residency curriculum. Eighty-one (89%) respondents reported their residency program or primary hospital emergency department (ED) had a dedicated ultrasound machine. BU was performed most commonly for the following: the FAST scan (focused abdominal sonography for trauma, 79/87%); cardiac examination (for tamponade, pulseless electrical activity, etc., 65/71%); transabdominal (for intrauterine pregnancy, ectopic pregnancy, etc., 58/64%); and transvaginal (for intrauterine pregnancy, ectopic pregnancy, etc., 45/49%). One to ten hours of lecture on BU was provided in 43%, and one to ten hours of hands-on clinical instruction was provided in 48% of the EM programs. Emergency physicians were identified as the faculty most commonly involved in teaching BU to EM residents (86/95%). Sixty-one (69%) programs reported that EM faculty and/or residents made clinical decisions and patient dispositions based on the ED BU interpretation alone. Fourteen (19%) programs reported that no formal quality assurance program was in place. CONCLUSIONS: The majority of ACGME-accredited EM residency programs currently incorporate BU training as part of their curriculum. The majority of BU instruction is done by EM faculty. The most commonly performed BU study is the FAST scan. The didactic component and clinical time devoted to BU instruction are variable between programs. Further standardization of training requirements between programs may promote increasing standardization of BU in future EM practice.     

Pediatric Emergency Medicine Education in Emergency Medicine Training Programs

BACKGROUND: The educational goal of emergency medicine (EM) programs has been to prepare its graduates to provide care for a diverse range of patients and presentations, including pediatric patients. OBJECTIVE: To evaluate the methods used to teach pediatric emergency medicine (PEM) to EM residents. METHODS: A written questionnaire was distributed to 118 EM programs. Demographic data were requested concerning the type of residency program, number of residents, required pediatric rotations, elective pediatric rotations, type of hospital and settings in which pediatric patients are seen, and procedures performed. Information was also requested on the educational methods used, proctoring EM received, and any formal curriculum used. RESULTS: Ninety-four percent (111/118) of the programs responded, with 80% of surveys completed by the residency director. Proctoring was primarily performed by PEM attendings and general EM attendings. Formal means of PEM education most often included the EM core curriculum (94%), journal club (95%), EM grand rounds (94%), and EM morbidity and mortality (M&M) conference (91%). Rotations and electives most often included the pediatric intensive care unit (PICU) and the emergency department (ED) (general and pediatric). CONCLUSIONS: Emergency medicine residents are exposed to PEM primarily by rotating through a general ED, the PED, and the PICU, being proctored by PEM and EM attendings and attending EM lectures and EM M&M conferences. Areas that may merit further attention for pediatric emergency training include experience in areas of neonatal resuscitation, pediatric M&M, and specific pediatric electives. This survey highlights the need to describe current educational strategies as a first step to assess perceived effectiveness.     

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.     

Emergency Medicine Residency Training in Electrocardiogram Interpretation

OBJECTIVES: A national survey of emergency medicine (EM) residency program directors (PDs) was conducted to review training and evaluation of residents in electrocardiogram (ECG) interpretation and to assess the attitudes of PDs toward establishing national criteria for ECG competency. METHODS: An eight-question multiple-part survey was mailed to all 122 EM PDs. The presence of a formal ECG curriculum, teaching formats, and methods to assess competency were queried. The PDs' opinions on developing a national ECG curriculum, standardized assessment tool, and competency requirement for graduation were solicited on a five-point Likert scale. RESULTS: Surveys were received from 87 (71.3%) of the 122 EM residency programs. Of the responding programs, 56 (64.4%) had a formal ECG curriculum. Only 18 (20.7%) programs stated that they test for ECG competency, and even fewer, ten (11.5%) programs, require that residents prove competency to graduate. Although 32 (48.3%) PDs endorsed the idea of a national ECG curriculum, 51 (58.6%) opposed the implementation of a national ECG examination for EM. Similarly, 50 (57.5%) PDs opposed a national ECG competency requirement for graduation. CONCLUSIONS: While a majority of EM residency programs surveyed have a formal curriculum for ECG interpretation, less than a fourth formally test their residents or require proof of competency. The majority of residency PDs oppose the development of a national ECG examination or competency requirement for graduation. Implementation of the Accreditation Council for Graduate Medical Education directive for the demonstration of clinical competencies will be challenging given the current position of PDs.     

The Development of a National Emergency Medical Services Curriculum Framework for Physicians in Canada

Background. As the role of emergency medical services (EMS) continues to expand, EMS physicians andmedical directors require special skills andtraining to keep pace with the rapidly evolving subspecialty of EMS. In Canada, subspecialty training in EMS is still relatively new, anda standard national curriculum for physician EMS training does not exist. Objective. To develop a national EMS curriculum for emergency medicine (EM) residents andfellows andan abbreviated curriculum for non-EM trainees andcommunity physicians. Methods. The authors obtained EMS curricula andopportunities from Canadian EM andEMS training programs anda sample of U.S. programs to determine existing curricula, anddeveloped a framework for a national EMS curriculum using an expert working group of EMS medical directors andEMS leaders in Canada. Results. Canadian EM residency training programs included an EMS rotation, but their content anddepth of training were not uniform. The expert working group proposed a comprehensive set of training objectives, grouped into 16 categories, stratified by level of training. Conclusion. The proposed framework andobjectives are suitable for training medical students, family medicine trainees, community physicians, EM residents, andEMS fellows in Canada. The authors hope this article will serve as a guideline for residency andfellowship directors to develop their EMS training programs in a consistent manner, promote formal training for physicians involved in EMS, andhelp define the specific knowledge andexpertise required of physicians who provide EMS medical direction in Canada.     

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.     

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.     

Perceptions of emergency medicine residents on the quality of residency training in the United States and Saudi Arabia

BACKGROUND: We compare educational environments (i.e. physical, emotional and intellectual experiences) of emergency medicine (EM) residents training in the United States of America (USA) and Saudi Arabia (SA).METHODS: A cross-sectional survey study was conducted using an adapted version of the validated Postgraduate Hospital Educational Environment Measure (PHEEM) survey instrument from April 2015 through June 2016 to compare educational environments in all emergency medicine residency programs in SA and three selected programs in the USA with a history of training Saudi physicians. Overall scores were compared across programs, and for subscales (autonomy, teaching, and social Support), using chi-squared, t-tests, and analysis of variance. RESULTS: A total of 219 surveys were returned for 260 residents across six programs (3 SA, 3 USA), with a response rate of 84%. Program-specific response rates varied from 79%-100%. All six residencies were qualitatively rated as “more positive than negative but room for improvement”. Quantitative PHEEM scores for the USA programs were significantly higher: 118.7 compared to 109.9 for SA, P=0.001. In subscales, perceptions of social support were not different between the two countries (P=0.243); however, role autonomy (P<0.001) and teaching (P=0.005) were better in USA programs. There were no significant differences by post-graduate training year. CONCLUSION: EM residents in all three emergency medicine residency programs in SA and the three USA programs studied perceive their training as high quality in general, but with room for improvements. USA residency programs scored higher in overall quality. This was driven by more favorable perceptions of role autonomy and teaching. Understanding how residents perceive their programs may help drive targeted quality improvement efforts.     

Emergency Medicine Resident Moonlighting: A Survey of Program Directors

OBJECTIVES: 1) To systematically describe emergency medicine (EM) program directors' perceptions of the benefits and risks of resident moonlighting. 2) To assess moonlighting policies of EM residencies, the degree of compliance with these policies, and the methods of dealing with residents who are out of compliance. METHODS: A written survey was mailed or hand-delivered to all allopathic and osteopathic EM residency directors in the United States in 1992-93. Incomplete and ambiguous surveys were completed by phone. RESULTS: There was a 96% response rate (113/118). The average EM resident clinical workweek ranged from 38 to 50 hours while the resident was assigned to ED rotations. Most (90%) of the program directors believe moonlighting interferes with residency duties to some degree. Few (10%) programs prohibit moonlighting altogether, although 44% limit moonlighting to an average of 41.5 hours per month. Program directors believe residents moonlight primarily for financial reasons. Most (60%) of the program directors believe moonlighting offers experience not available in the residency, primarily related to autonomous practice. Fifteen programs reported residents who had been sued for malpractice while moonlighting, with one program director named along with the resident. One third of program directors have penalized residents for abuse of moonlighting privileges. CONCLUSIONS: EM residency directors are concerned about the effect of moonlighting on resident education. The directors' concerns regarding litigation, excessive work hours, and interference with residency duties are balanced by a general acceptance of the financial need to supplement residency income.     

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.     

Predictors of Success in Emergency Medicine Ultrasound Education

OBJECTIVES: To compare emergency medicine resident performance on an ultrasound-oriented, American Board of Emergency Medicine-styled written examination with the following variables in resident education: number of ultrasound scans performed, presence of a formal, structured ultrasound rotation, presence of a mandatory ultrasound rotation, number of hours of didactic ultrasound education, and percentage of ultrasound education taught by emergency physicians. METHODS: This was a prospective cohort study involving 14 residency programs. A 60-question multiple-choice test was completed by individual residents and returned for scoring. RESULTS: 262 residents completed the study. Average score was 39.1/60 +/- 6.5 (65%). Scores improved as residency year increased (year 1: 36.6, year 2: 39.3, year 3: 42.6) (p < 0.005). Scores improved as number of scans performed increased from 34.3 (57%) for those residents who had performed 0-10 scans to 45.4 (76%) for those with >150 scans (p < 0.005). The presence of an ultrasound rotation at an emergency medicine residency program also produced a statistically significant increase in test score (OR 1.82; 95% CI = 1.29 to 2.55). Residents at programs spending the least time (6 to 15 hours) on didactic education throughout the residency predicted examination failure (OR 0.60; 95% CI = 0.39 to 0.93). Increasing the amount of resident ultrasound teaching by emergency physicians improved the score, but this did not reach significance (p = 0.357). CONCLUSIONS: Improved resident performance on an ultrasound written examination was associated with increasing resident year, number of scans performed, and the presence of an ultrasound rotation at the residency program. Increasing the number of didactic hours spent on ultrasound each year beyond 15 hours showed no improvement in resident performance.     

Need for Standardized Sign-out in the Emergency Department: A Survey of Emergency Medicine Residency and Pediatric Emergency Medicine Fellowship Program Directors

Objectives
To determine the existing patterns of sign-out processes prevalent in emergency departments (EDs) nationwide. In addition, to assess whether training programs provide specific guidance to their trainees regarding sign-outs and attitudes of emergency medicine (EM) residency and pediatric EM fellowship program directors toward the need for the development of standardized guidelines relating to sign-outs.
Methods
A Web-based survey of training program directors of each Accreditation Council for Graduate Medical Education (ACGME)–accredited EM residency and pediatric EM fellowship program was conducted in March 2006.
Results
Overall, 185 (61.1%) program directors responded to the survey. One hundred thirty-six (73.5%) program directors reported that sign-outs at change of shift occurred in a common area within the ED, and 79 (42.7%) respondents indicated combined sign-outs in the presence of both attending and resident physicians. A majority of the programs, 119 (89.5%), stated that there was no uniform written policy regarding patient sign-out in their ED. Half (50.3%) of all those surveyed reported that physicians sign out patient details "verbally only," and 79 (42.9%) noted that transfer of attending responsibility was "rarely documented." Only 34 (25.6%) programs affirmed that they had formal didactic sessions focused on sign-outs. A majority (71.6%) of program directors surveyed agreed that specific practice parameters regarding transfer of care in the ED would improve patient care; 80 (72.3%) agreed that a standardized sign-out system in the ED would improve communication and reduce medical error.
Conclusions
There is wide variation in the sign-out processes followed by different EDs. A majority of those surveyed expressed the need for standardized sign-out systems.     

Competence of New Emergency Medicine Residents in the Performance of Lumbar Punctures

Background: Medical students are taught some procedural skills during medical school, but there is no uniform set of procedures that all students learn before residency. Objective: To determine the level of competence in the performance of a lumbar puncture (LP) by new postgraduate year 1 (PGY1) emergency medicine (EM) residents. Methods: An observational study was conducted at three EM residencies with 42 PGY1 residents who recently graduated from 26 various medical schools. The LP procedure was divided into 26 major and 44 minor steps to create a scoring protocol. The model, procedure, and scoring protocol were validated by experienced emergency physicians. Subjects performed the procedure without interruption or feedback on an LP training model using a standard LP kit. A step was scored as “performed correctly” if two of the three evaluators concurred. Pre‐ and poststudy questionnaires assessed subjects' prior instruction and clinical experience with LP, self‐confidence, sense of relevance, motivation, and fatigue. Results: Subjects completed an average of 14.8 (57%; 95% confidence interval [95% CI] = 53% to 61%) of the major steps (range: 4–26) and 19.1 (43%; 95% CI = 42% to 45%) of the minor steps (range: 7–28) in 14.3 minutes (range: 3–22). Sixty‐nine percent failed to obtain cerebrospinal fluid from the model. Subjects' levels of confidence changed slightly on a five‐point scale from 2.8 (“little‐to‐some”) before the test to 2.5 after the test. Eighty‐three percent of the subjects previously performed LPs on patients during medical school (average attempts = 2.2; range: 0–10), but only 40% of those who did so were supervised by an attending during their first attempt. Conclusions: In the cohort studied, new PGY1 EM residents had not attained competence in performing LPs from training in medical school. Most new PGY1 residents probably require training, practice, and close, direct supervision of this procedure by attending physicians until the residents demonstrate competent performance.     

Declining Rate of Cricothyrotomy in Trauma Patients with an Emergency Medicine Residency: Implications for Skills Training

Objective: To report the change in cricothyrotomy rate with emergency medicine (EM) residency development and to address the implications for training in this skill.
Methods: A retrospective chart review was used to determine the cricothyrotomy rate at a 1,000-bed urban Level-1 trauma center with EM, surgery, and anesthesiology residencies. All adult trauma patient visits to the ED between July 1, 1985, and June 30, 1995, were reviewed. The cricothyrotomy rate was defined as the total number of cricothyrotomies per trauma admissions during a study phase.
Results: The study period was divided into 3 phases. Phase 1 (academic years 1985–1989): prior to the inception of the EM residency; phase 2 (academic years 1990–1992): initiation and establishment of the residency; and phase 3 (academic years 1993–1994): full implementation of the EM residency. The cricothyrotomy rate during phase 1 was 1.8% (95% CI: 1.6 to 2.0), vs 1.1% (95% CI: 0.0 to 2.8) and 0.2% (95% CI: 0.0 to 0.2) during phases 2 and 3, respectively.
Conclusions: The cricothyrotomy rate decreased with the full implementation of the EM residency. Whether this trend was an effect of the presence of an EM faculty and residency training program, a parallel approach to airway management nationwide, or another unidentified factor will require further investigation. Nonetheless, given the increasing rarity of this procedure, it is likely that many EM, surgical, and anesthesiology residents will not acquire clinical experience with this technique during training.