Direct Observation of Residents in the Emergency Department: A Structured Educational Program

Objectives:  The objective was to describe the implementation of a program of structured direct observation of emergency medicine (EM) residents during clinical shifts in the emergency department (ED).
Methods:  The authors developed a program in which an observer spent 4 to 5 hours with each resident, without intervening in the clinical encounters. A structured data form was developed to document the resident's performance in a number of defined clinical areas relevant to patient care and mastery of the core competencies. Individual strengths and weaknesses were noted, and the observer provided directed feedback at the end of the session.
Results:  Over an 18-month period, 32 EM residents were observed during their ED shifts. The sessions not only provided specific information on individual residents' performances, but also identified areas where the residency program curriculum could be enhanced and provided a means of assessing mastery of the core competencies. In addition, the program provided an opportunity to give detailed and timely directed feedback to residents. Both residents and attending staff found the sessions acceptable and useful.
Conclusions:  Implementation of a structured direct observation program was feasible and well received and provided insight into the strengths and weaknesses of residents both individually and as a group.     

Evaluation of Resident Performance and Intensive Bedside Teaching during Direct Observation

Objective: To describe the experience of a residency program in emergency medicine with an intensive observational evaluation of resident performance in the ED.
Methods: Each resident was directly observed and evaluated during a clinical shift four times each academic year: once by each residency codirector and twice by the resident's faculty advisor. The faculty members performed this evaluation outside of "clinical staffing time," shadowing the resident for several hours in the ED during the resident's assigned shift. The resident and assigned faculty member discussed the patients' histories and physical examination findings and developed treatment plans together. Prior to initiation of the observation, the faculty were provided with guidelines for the evaluation of specific skills. Immediate feedback of strengths and deficiencies was provided to the resident.
Results: Subjective evaluations by faculty suggest that new insights into resident clinical strengths and weaknesses were determined using this approach. Objective scoring of resident performance demonstrated heterogeneity of skills between residents as well as inconsistency of skills for specific residents.
Conclusions: The program provided the faculty with protected teaching time, an opportunity to share clinical pearls, and unique insights into resident performance that are not obvious during standard clinical interactions.     

9 A Communication Tool for Emergency Medicine Residents to Improve Patient Care and Professional Development

For every patient in the ED, a web of communication is created. A resident is at the center of this web – connecting team members in and outside the ED. Careful communication, a required ACGME competency, helps the team provide safe, high-quality care and master their respective specialties. We designed a three module curriculum that supports ACGME core competencies by providing training in professional communication and a framework with which to organize patient data. In the first module, residents are introduced to the concept that there is more to communication than content alone. Other elements include context, audience and forum. Together, these components comprise relevant communication. The second module introduces the Disposition, Situation, Background, Assessment, Recommendation, Safety (D-SBARS) Framework, an ED modification of The Joint Commission's communication tool. This framework will enable the resident to focus on communicating the relevant data for a particular audience in an appropriate manner. In the last module, residents participate in a case-based role-play. After presentation of a complicated patient, residents are each assigned a communication task. They communicate with attendings, ED staff and consultants. Each role is played by senior residents. Finally, participants deliver presentations to the on-coming team on "rounds" under time constraints, declining from two minutes to 30 seconds. Residents experience how the D-SBARS tool helps them communicate critical clinical and safety.     

11 Dawn Patrol Patient Follow-up Protocol

Follow-up of patients after their emergency department course provides a rich educational experience for residents, but due to time and logistical constraints, is infrequently performed in a scheduled and rigorous manner. The Dawn Patrol initiative was added to our residency curriculum to facilitate and protocolize patient follow-up for education and feedback on patient care. It also strives to improve communication with inpatient services, and provides a means of collection for morbidity / mortality and risk management cases. Our process functions by charging the clinical senior resident who is going off-shift, with reviewing the admission record for the past 24 hours. Interesting, clinically important, or cryptic case presentations are selected via our electronic medical record for review at the end of Morning Report. Generally, 1-3 new cases are selected for review each weekday morning. These cases are then recorded on a dry erase board in the Morning Report room, and the cases are followed until inpatient discharge, or are no longer of clinical interest. Visits to the inpatient wards are encouraged. Patient callbacks of outpatients are also eligible for inclusion. The cases are updated daily, and generally 5-10 cases are reviewed per day in approximately 10 minutes. The staff member attending Morning Report is responsible for providing bulleted teaching points on each case. The Dawn Patrol patient follow-up initiative seeks to improve emergency medicine resident education by facilitating and protocolizing patient follow-up, and provides real-time feedback on patient care performed in the emergency department.     

14 The Use of Medical Simulation to Enhance the Clinical Exposure to International Emergency Medicine

Study Objectives:  Increasing numbers of immigrants and returned travelers use emergency departments for health care. Many physicians-in-training are interested in participating in health electives abroad, yet residency curricula generally address global health inadequately. Advanced medical simulation (SIM) is an educational modality used to artificially re-create clinical experiences. Authors explored the application of SIM and standardized patient encounters to teach emergency medicine residents select topics in tropical medicine, public health, and decision-making in varied-resource settings.
Methods:  International Emergency Medicine (IEM) faculty created four case scenarios interspersed into the established residency simulation curriculum. Moulaged manikins and standardized patients in immersive IEM clinical settings provided history and physical exam cues to learners during the following clinical encounters:
- "Tent-side" mobile clinic, East Africa: "Dizzy" pregnant patient (Hookworm).
- Rural health clinic, Southeast Asia: Infant with "altered mental status" (Dengue).
- Emergency department, North America: Central American immigrant with "dyspnea" (Chagas).
- Emergency department, North America: Returned traveler from East Africa with "fever" (Typhoid).
Post-scenario debriefings addressed unique elements of IEM including     

Life situation and daily life in a nursing home as described by nursing home residents in Sweden

Aims and objectives.  The overall aim of this study was to investigate nursing home residents' opinion of their life situation in a nursing home and of their earlier life.
Background.  Few studies have focused on residents' perception of their daily life and life situation in nursing homes.
Design.  A qualitative explorative design was used.
Methods.  Residents in a nursing home were interviewed and qualitative content analysis was performed.
Results.  The views of life residents described and how they apprehended their situation were quite different. The findings give an understanding of what it is like to live in a nursing home and show that residents apprehend their situation in very different ways. All individuals who were content with their situation in the nursing home were also content with their earlier life.
Relevance to clinical practice.  For the nurse in gerontological care, it is a challenge to get to know each resident and to provide the best nursing care and the best individual treatment for each resident. Another challenge is to help each resident find a life in the nursing home that is acceptable for him/her, and one aspect of this involves helping residents in their ageing process. The present study highlights what an important role staff have in relation with nursing home residents.     

Emergency Medicine Resident Self-assessment of Clinical Teaching Compared to Student Evaluation Using a Previously Validated Rubric

Purpose

The quality of clinical teaching in the emergency department from the students' perspective has not been previously described in the literature. Our goals were to assess senior residents' teaching ability from the resident/teacher and student/learner viewpoints for any correlation, and to explore any gender association. The secondary goal was to evaluate the possible impact of gender on the resident/student dyad, an interaction that has previously been studied only in the faculty/student pairing.

An Educational Strategy for Teaching Standardized Nursing Languages

PURPOSE.  The aim of this paper is to describe an educational strategy for teaching standardized nursing languages (SNL) used in both the classroom and clinical components of a psychiatric–mental health nursing course at the associate degree level.
DATA SOURCES.  Data included a review of the relevant literature, teaching experiences, and faculty and student experiences.
DATA SYNTHESIS.  Enhancing associate degree student nurses' competency regarding diagnosis and interventions is essential to influence positive health outcomes. Use of diagnostic, outcome, and intervention classifications for learning nursing care promotes critical thinking, individualization of nursing care, and students' fluency with SNL. One possible teaching strategy to assist students to learn and use SNL was implemented through the use of a faculty-developed Student Nurse Documentation Packet.
CONCLUSIONS.  The educational strategy provided students opportunities to enhance their experience with the SNL to plan and document care of individuals experiencing psychiatric–mental health problems.
IMPLICATIONS FOR NURSING.  The educational strategy used in this program was judged to be successful. Research is needed to provide empirical evidence of the efficacy of this pedagogical strategy for increasing knowledge and enhancing students' competency.     

12 Highly Interactive Teaching: A "HIT" with Residents

Covering the core content of emergency medicine during residency training is both a time consuming and challenging endeavor. One of the more significant challenges in graduate medical education is to develop more interactive, less didactic teaching modalities. In an attempt to develop a more interactive educational curriculum, we interspersed weekly sessions titled "Highly Interactive Teaching" (HIT) with standard formal lecture didactics. A primary focus of many educators in emergency medicine is teaching residents how to manage the undifferentiated patient. To this end, we revised our curriculum to include 34 four-hour symptom/chief complaint-based sessions. The first hour is an introductory lecture on the general approach to a patient with the specified complaint. Residents then divide into small groups which rotate through specific case-based sections covering varied diagnoses which might present with the symptom complaint. These faculty-run small groups use a case-based approach, either high or low simulation-based or oral boards-based format. Each faculty then is required to sum up the salient points of their section. The final hour of the day is an evidenced-based review of supporting literature. Residents are required to read and critique selected articles for the audience so that the basis for diagnosis and management decisions can be discussed as a large group discussion. We believe this change in format will help residents not only to become more active learners, but also to become more astute clinicians.     

Improving Communication Skills: Feedback from Faculty and Residents

Objectives: To determine common themes in faculty and peer feedback for emergency medicine (EM) resident oral presentations.
Methods: From January to July 2005, all EM residents received written feedback on communication skills from two faculty and two peer reviewers. The feedback forms were analyzed by using formal grounded theory. The two investigators independently reviewed 25% of the forms to generate a code of general categories and specific qualifiers. The independent codes were merged by consensus into a common code. All forms were independently coded by the two investigators using the common code. Coding disagreements were resolved by consensus, yielding a uniform inventory of feedback categories and qualifiers.
Results: Twenty-one of 23 residents participated. Three hundred seventy-two data points were coded, with an interrater agreement of 85.7%. The five most common feedback themes were as follows: focus on key and relevant teaching points; increase audience participation; encourage higher level thinking; decrease content per slide; and add missing content relevant to teaching point . Peers differed from faculty, mentioning more frequently encourage higher level thinking and add missing content relevant to teaching point . Faculty differed from peers, mentioning increase clarity of teaching point and be engaging and enthusiastic more frequently. The difference in distribution of themes between faculty and peers was significant (χ²= 59.692; p = 0.01).
Conclusions: The authors present a model for providing feedback to EM residents on communication skills that is individualized, behavior based, and includes peer comments. Faculty and peers differ in their recommendations. The findings may inform communication skills curricula for EM residents.     

Evaluation of the Educational Utility of Patient Follow-up

OBJECTIVES: To date, no studies in emergency medicine (EM) have addressed the educational value of the Residency Review Committee for Emergency Medicine's (RRC-EM) requirement for patient follow-up (FU). The authors examined whether performance of patient FU improved EM resident education. METHODS: All EM resident FU encounters from September 25, 2001, through September 24, 2002, were documented and analyzed. All EM residents at a regional tertiary referral emergency department (ED) initiated patient FU encounters by entering information regarding patients' initial ED presentations into a Web-based follow-up system (WBFUS), subsequently entered FU information, and indicated whether they thought that the specific FU encounters improved their education (yes/no). Supervising faculty members then reviewed the residents' completed FU entries. Blinded to residents' responses regarding educational utility, faculty members evaluated whether they thought the specific FU encounters were educational for the residents (yes/no). Data entered into the WBFUS were then summarized as percentages. RESULTS: Eight hundred forty-seven FU encounters were completed by 18 EM residents and 29 EM faculty. Ninety-three percent of the FU entries were deemed by at least one evaluator (resident or faculty) to have educational value. Residents found the act of performing FU educational in 81.3% of cases, whereas faculty thought 80.4% were educational for the resident. Although the residents and faculty agreed on the educational value in 75.4% of cases, the overall strength of the agreement was slight to fair (kappa statistic = 0.21). CONCLUSIONS: This study indicates that EM residents and faculty believe that the act of performing patient FU has educational value for EM residents; however, the interobserver agreement between residents and faculty was low.     

Feedback

The emergency department provides a rich environment for diverse patient encounters, rapid clinical decision making, and opportunities to hone procedural skills. Well-prepared faculty can utilize this environment to teach residents and medical students and gain institutional recognition for their incomparable role and teamwork. Giving effective feedback is an essential skill for all teaching faculty. Feedback is ongoing appraisal of performance based on direct observation aimed at changing or sustaining a behavior. Tips from the literature and the author's experience are reviewed to provide formats for feedback, review of objectives, and elements of professionalism and how to deal with poorly performing students. Although the following examples pertain to medical student education, these techniques are applicable to the education of all adult learners, including residents and colleagues. Specific examples of redirection and reflection are offered, and pitfalls are reviewed. Suggestions for streamlining verbal and written feedback and obtaining feedback from others in a fast-paced environment are given. Ideas for further individual and group faculty development are presented.     

Effect of an Integrated Public Health Curriculum in an Emergency Medicine Residency

Background: Emergency departments (EDs) serve as a central point of interaction between the public and the medical system. Emergency physicians need education in public health in order to optimize their clinical care and their ability to evaluate potential public health interventions in the ED. Methods: As part of the Centers for Disease Control and Prevention (CDC) and the Association of American Medical College's (AAMC) national initiative for "Regional Medicine-Public Health Education Centers-Graduate Medical Education", we designed and implemented a new public health curriculum for the emergency medicine residents. Over four sessions during regular didactic time, we used a modular approach to link a basic public health principle, such as environmental hazard assessment, to a relevant clinical topic, such as violent patients and ED safety. Each session emphasized resident involvement, including small group work and role-plays. Journal clubs and quality assurance projects supplemented the curriculum. We sought resident feedback through focus groups and anonymous online pre- and post-tests for each session. Assessment: Both before and after the curriculum, 76% of responders felt it was important for physicians to receive training in public health. The program appeared to have a positive effect on residents' comfort level with various public health topics, and felt the residency program had taught them the skills necessary to implement public health principles in clinical practice (23.8%, versus 11.5% before; p<0.05). Conclusions: Integration of public health principles into existing clinical curricula in emergency medicine may increase resident interest and knowledge. Combining public health and emergency medicine topics in regular didactic conferences facilitates public health education for residents.     

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.     

Students’ and residents’ ratings of teaching effectiveness in a department of pediatrics

We analyzed an instrument for measuring overall teaching effectiveness in the Department of Pediatrics at the Medical College of Wisconsin.

Over 18 months, we prospectively collected 2,101 teacher evaluations from medical students and residents using a Likert scale evaluating overall teaching effectiveness and nine component traits.

The mean rating (5.62, SD = 1.13) for overall teaching effectiveness (OTE) correlated most highly (r = .83) with the average scores across traits (M = 5.61, SD = .95), although Pearson correlation coefficients of OTE with all traits were all significant (p < .001). Multiple regression showed that being clear/organized, demonstrating enthusiasm, and developing rapport accounted for 71% of the variance (p < .001). Although the inpatient ward rotation had lower OTE mean ratings (p < .0001), individual's OTE ratings in different settings did not differ significantly. OTE mean ratings were positively associated with longer duration of interaction (p < .0001) but not by the evaluator's level of training. The form had the necessary internal consistency (a = .94).

Based on student/resident evaluations, the OTE rating was the best single indicator summarizing global teaching effectiveness. Our form was shown to be reliable and useful for faculty development and administrative decisions, and teaching ability was not influenced by the setting.     

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.     

Impacting Faculty Teaching and Student Performance: Nine Years' Experience With the Objective Structured Clinical Examination

Background: The impetus for administering the 2nd-year Objective Structured Clinical Examination (OSCE) came from the great variability in student performance observed by 3rd-year clerkship directors. Purpose: To document the effects of the OSCE on faculty teaching, student performance, and the curriculum over 9 years of administration of the examinations to more than 1,000 second-year medical students. Method: A 20-station OSCE was administered to all medical students at the end of their 2nd year. Using predetermined criteria, clinical faculty served as evaluators in each station. A mix of 1st-, 3rd-, and 4th-year medical students were recruited to serve as simulated patients. Faculty evaluators and examinees completed a questionnaire evaluating their experience with the OSCE. Students received a report card of their performance. Small-group leaders of the Introduction to Clinical Medicine course received feedback on their group's performance on each station compared to the class mean. Summative data on class performance was reported to the curriculum committee. The academic status committee received data on students who performed unsatisfactorily. Results: Faculty and examinee ratings of the OSCE experience were very positive. Over the 9-year period, student performance improved showing less variability and significantly fewer failed stations. Conclusion: The OSCE has proven to be a technically feasible, authentic evaluation method yielding valuable information for decisions regarding student performance, faculty teaching, and curriculum planning.     

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.