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.     

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.     

Resident Educational Time Study: A Tale of Three Specialties

Abstract. Objectives : To compare amounts of in-hos-pital time use by PGY1 residents during rotations in emergency medicine (EM), internal medicine (IM), and surgery. This article reports the general study methodology and focuses on the educational aspects of residency time use. Methods : A cross-sectional, observational study of the activities of EM PGY1 residents was performed while the residents were on duty during the 3 specialty rotations. The activities were recorded by an observer using a log with predetermined categories for clinical/service, educational, and personal areas. 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. Results : Twelve PGY1 residents were observed for a total of 166 hours on surgery, 156 hours on IM, and 120 hours on EM. These hourly amounts were representative of a typical 2-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, 24% on educational activities, and 19% on personal activities. The proportions of time devoted to the 3 major areas were similar for the 3 rotations. In all 3 rotations, the largest proportion of time was spent on patient-focused education (81% to 92% of total educational time). Only 2% to 11% of educational time was devoted to self-education. Within the patient-focused education category, proportionately less resident time with faculty occurred on the surgery rotation than on the EM and IM rotations (18% vs 30% and 27%, respectively). Conclusion : The general breakdowns of clinical/service, educational, and personal time use by PGY1 residents are proportionately similar for the 3 service rotations. Patient-focused education is the primary mode of education for all services. In-hospital, self-education time is limited. Clinical teaching is largely by nonfaculty. The educational implications of these findings are discussed.     

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.     

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.     

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 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.     

A Case–based Emergency Medicine Curriculum for Senior Medical Students

Objective: To determine the effects of a case–based, core content–oriented emergency medicine (EM) curriculum on the basic EM knowledge of senior medical students.
Methods: All senior medical students rotating through the Milwaukee County EM elective during the 1992–1993 academic year were assigned specific chapter readings from a case–oriented EM textbook. A course curriculum consisting of goals and objectives for each chapter and two to three representative cases for the discussion topic also was distributed to each student. Interspersed with the cases was a series of questions directed at pathophysiology, diagnosis, management, and disposition. The EM faculty and residents conducted case discussions three times per week. AH students completing the rotation were given a pretest at the beginning and a final examination at the end of the rotation. In addition, the students rated the textbook, coursebook, and lecture series at the end of the rotation using a five–point Likert scale.
Results: Seventy–five students rotated through the elective. The students showed a significant improvement in their EM knowledge base as judged by improvement in final examination scores compared with pretest scores (pretest score 62.2 ± 7.1%; final examination score 76.2 ± 6.3%; p < 0.0001). The mean change in scores was 14.8%, with a range of –1.6% to 34%. The students also rated the textbook, coursebook, and lecture series as effective, as shown by high median scores on a Likert scale.
Conclusions: A case–based EM curriculum coupled with ED clinical experience improves basic EM diagnostic and management knowledge of senior medical students.     

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.     

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.     

Questionnaire instrument to assess knowledge of chronic kidney disease clinical practice guidelines among internal medicine residents

Introduction  The National Kidney Foundation published Kidney Disease Outcomes Quality Initiative guidelines that recommend early detection and management of chronic kidney disease (CKD) and timely referral to a nephrologist. Many patients with CKD are seen by primary care doctors who maybe less experienced than a nephrologist to offer optimal early CKD care. It is not known whether postgraduate training adequately prepares a future internist in CKD management.
Methods  We developed a 15-item questionnaire instrument to assess knowledge of CKD guidelines among internal medicine residents in USA using an online survey programme. We studied the validity and reliability measures of our instrument.
Results  The survey was completed by 166 PGY1 (postgraduate year one), 187 PGY2 and 126 PGY3. The questionnaire tested various aspects of CKD including definition, classification, identification of risk factors, laboratory evaluation, development of clinical action plan, identification of complications, anaemia and bone and mineral disorder, referral to a nephrologist and medication use. Validity was supported by the use of official guidelines and an expert panel of nephrologists to develop content and improvement in mean test performance with increasing level of training (PGY1 59.2 ± 13.5%, PGY2 62.6 ± 12.3% and PGY3 64.3 ± 12.2%; P  = 0.002). The reliability coefficient for the questionnaire instrument (Cronbach's α) was 0.69.
Conclusion  Our brief questionnaire is a valid and reliable instrument to assess knowledge of CKD guidelines among internal medicine residents and identify specific gaps for improvement.     

A Model for an Integrated Emergency Medicine/Trauma Service

Objective: To describe a model for an integrated multidisciplinary trauma service and to compare survival outcomes for patients resuscitated by either emergency medicine (EM) or surgical housestaff assigned to the trauma service.
Methods: A prospective observational study was performed using injured patients evaluated in the trauma room at Hartford Hospital from July 1 through December 31, 1995. Inclusion criteria included an ICD-9-CM code of 800 through 959.9 and any of the following: transfer from another hospital, admission to the intensive care unit, hospitalization for ±23 hours, survival probability of ±90%, or Abbreviated Injury Score of ±3. Patients were excluded for burns necessitating transfer to a burn unit for definitive care, and for missing data elements that prevented a patient from being analyzed by the TRISS method. Data elements included mechanism of injury, Injury Severity Score, Revised Trauma Score, probability of survival, age, gender, and whether an EM resident was team leader. Patients in the EM cohort (group 1) were compared with patients for whom a surgical resident was team leader (group 2) for all data elements and for hospital survival. TRISS analysis was performed to evaluate outcomes in comparison with national norms.
Results: After exclusions, 609 patients were left for analysis. There were 141 (30%) resuscitated with an EM resident as team leader. No significant difference was found for matched variables between the groups. Both groups had good comparability with the Major Trauma Outcome Study (MTOS) database baseline, with M scores of 0.949 and 0.942, respectively. Outcomes for both groups also compared favorably with the MTOS norm for survival, with Z scores of 2.38 and 2.35 for groups 1 and 2.
Conclusions: These results suggest that in this model of integrated EW trauma service, equivalent survival outcomes occur whether EM or surgery housestaff act as team leaders.     

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.     

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.     

Brief Screening for Adolescent Depressive Symptoms in the Emergency Department

Background:  Depression is the most common psychiatric disorder among adolescents and is more prevalent among those seeking care in the emergency department (ED). However, adolescents are rarely screened for depressive symptoms in the pediatric emergency department (PED).
Objectives:  To evaluate the sensitivity and specificity of one- and two-item screens for depressive symptoms compared to the 20-question Center for Epidemiologic Studies Depression Scale (CESD) among adolescents seeking care in a PED.
Methods:  This was a cross-sectional study of a convenience sample of adolescents 12–17 years old presenting to an urban PED with subcritical illness or injury. Participants completed three screening instruments: the two-question screen, the single-question screen, and the CESD.
Results:  A total of 321 patients were approached to enter the study, of whom 212 (66%) agreed to participate. Seventy-eight (37%) of the study participants screened positive for depression on the CESD using a cutoff score of ≥16. The two-question screen had a sensitivity of 78% (95% confidence interval [CI] = 73% to 84%) and specificity of 82% (95% CI = 77% to 87%) for depressive symptoms compared with the CESD. The single-question screen had a sensitivity of 56% (95% CI = 50% to 63%) and specificity of 93% (95% CI = 90% to 96%) compared with the CESD.
Conclusions:  The two-question screen is a sensitive and specific initial screen for depressive symptoms in adolescents being seen in the PED. This quick, simple instrument would be ideal for use in the busy PED setting and would allow clinicians to identify adolescents who require more extensive psychiatric evaluation.     

Emergency Medicine Residents'' Shiftwork Tolerance and Preference

OBJECTIVES: To determine the shift lengths currently worked by emergency medicine (EM) residents and their shift length preferences, and to determine factors associated with EM residents' subjective tolerance of shiftwork. METHODS: A survey was sent to EM-2 through EM-4 allopathic EM residents in May 1996. This questionnaire assessed the residents' shift length worked, shift length preferences, night shift schedules, and self-reported ability to overcome drowsiness, sleep flexibility, and morningness-eveningness tendencies. When providing shift length preferences, the residents were asked to assume a constant total number of hours scheduled per month. RESULTS: Seventy-eight programs participated, and 62% of 1,554 eligible residents returned usable surveys. Current shift lengths worked were 8 hours (12%), 10 hours (13%), 12 hours (37%), combinations of 8-hour, 10-hour, or 12-hour (34%) shifts, and other combinations (4%). Seventy-three percent of the respondents indicated that they preferred to work 8-hour or 10-hour shifts, and only 21% preferred a 12-hour shift. Shiftwork tolerance was recorded as: not well at all (2%), not very well (14%), fairly well (70%), and very well (14%). The EM residents' eveningness preference, ability to overcome drowsiness, sleep flexibility, younger age, and having no children at home were all associated with greater shiftwork tolerance. CONCLUSIONS: Emergency medicine residents generally tolerate shiftwork well and prefer 8-hour or 10-hour shift lengths compared with 12-hour shift lengths. Emergency medicine residencies with 12-hour shifts should consider changing residents' shifts to shorter shifts.     

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.