#MeToo in EM: A Multicenter Survey of Academic Emergency Medicine Faculty on Their Experiences with Gender Discrimination and Sexual Harassment

Introduction: Gender-based discrimination and sexual harassment of female physicians are well documented. The #MeToo movement has brought renewed attention to these problems. This study examined academic emergency physicians’ experiences with workplace gender discrimination and sexual harassment.Methods: We conducted a cross-sectional survey of a convenience sample of emergency medicine (EM) faculty across six programs. Survey items included the following: the Overt Gender Discrimination at Work (OGDW) Scale; the frequency and source of experienced and observed discrimination; and whether subjects had encountered unwanted sexual behaviors by a work superior or colleague in their careers. For the latter question, we asked subjects to characterize the behaviors and whether those experiences had a negative effect on their self-confidence and career advancement. We made group comparisons using t-tests or chi-square analyses, and evaluated relationships between gender and physicians’ experiences using correlation analyses.Results: A total of 141 out of 352 (40.1%) subjects completed at least a portion of the survey. Women reported higher mean OGDW scores than men (15.4 vs 10.2; 95% confidence interval [CI], 3.6–6.8). Female faculty were also more likely to report having experienced gender-based discriminatory treatment than male faculty (62.7% vs 12.5%; 95% CI, 35.1%-65.4%), although male and female faculty were equally likely to report having observed gender-based discriminatory treatment of another physician (64.7% vs 56.3%; 95% CI, 8.6%-25.5%). The three most frequent sources of experienced or observed gender-based discriminatory treatment were patients, consulting or admitting physicians, and nursing staff. The majority of women reported having encountered unwanted sexual behaviors in their careers, with a significantly greater proportion of women reporting them compared to men (52.9% vs 26.2%, 95% CI, 9.9%-43.4%). The majority of unwanted behaviors were sexist remarks and sexual advances. Of those respondents who encountered these unwanted behaviors, 22.9% and 12.5% reported at least somewhat negative effects on their self-confidence and career advancement.Conclusion: Female EM faculty perceived more gender-based discrimination in their workplaces than their male counterparts. The majority of female and approximately a quarter of male EM faculty encountered unwanted sexual behaviors in their careers.

Group treatments for sensitive health care problems : a randomised controlled trial of group versus individual physiotherapy sessions for female urinary incontinence

Background: The aim was to compare effectiveness of group versus individual sessions of physiotherapy in terms of symptoms, quality of life, and costs, and to investigate the effect of patient preference on uptake and outcome of treatment. Methods: A pragmatic, multi-centre randomised controlled trial in five British National Health Service physiotherapy departments. 174 women with stress and/or urge incontinence were randomised to receive treatment from a physiotherapist delivered in a group or individual setting over three weekly sessions. Outcome were measured as Symptom Severity Index; Incontinence-related Quality of Life questionnaire; National Health Service costs, and out of pocket expenses. Results: The majority of women expressed no preference (55%) or preference for individual treatment (36%). Treatment attendance was good, with similar attendance with both service delivery models. Overall, there were no statistically significant differences in symptom severity or quality of life outcomes between the models. Over 85% of women reported a subjective benefit of treatment, with a slightly higher rating in the individual compared with the group setting. When all health care costs were considered, average cost per patient was lower for group sessions (Mean cost difference £52.91 95%, confidence interval (£25.82 - £80.00)). Conclusion: Indications are that whilst some women may have an initial preference for individual treatment, there are no substantial differences in the symptom, quality of life outcomes or non-attendance. Because of the significant difference in mean cost, group treatment is recommended

Prehospital randomised assessment of a mechanical compression device in cardiac arrest (PaRAMeDIC) trial protocol

Background Survival after out-of-hospital cardiac arrest is closely linked to the quality of CPR, but in real life, resuscitation during pre-hospital care and ambulance transport is often suboptimal. Mechanical chest compression devices deliver consistent chest compressions, are not prone to fatigue and could potentially overcome some of the limitations of manual chest compression. However, there is no high-quality evidence that they improve clinical outcomes, or that they are cost effective. The Pre-hospital Randomised Assessment of a Mechanical Compression Device In Cardiac Arrest (PARAMEDIC) trial is a pragmatic cluster randomised study of the LUCAS-2 device in adult patients with non-traumatic out-of-hospital cardiac arrest. Methods The primary objective of this trial is to evaluate the effect of chest compression using LUCAS-2 on mortality at 30 days post out-of-hospital cardiac arrest, compared with manual chest compression. Secondary objectives of the study are to evaluate the effects of LUCAS-2 on survival to 12 months, cognitive and quality of life outcomes and cost-effectiveness. Methods: Ambulance service vehicles will be randomised to either manual compression (control) or LUCAS arms. Adult patients in out-of-hospital cardiac arrest, attended by a trial vehicle will be eligible for inclusion. Patients with traumatic cardiac arrest or who are pregnant will be excluded. The trial will recruit approximately 4000 patients from England, Wales and Scotland. A waiver of initial consent has been approved by the Research Ethics Committees. Consent will be sought from survivors for participation in the follow-up phase. Conclusion The trial will assess the clinical and cost effectiveness of the LUCAS-2 mechanical chest compression device. Trial Registration: The trial is registered on the International Standard Randomised Controlled Trial Number Registry (ISRCTN08233942)

Is protocolised weaning that includes early extubation onto non-invasive ventilation more cost effective than protocolised weaning without non-invasive ventilation? Findings from the Breathe Study

Background Optimising techniques to wean patients from invasive mechanical ventilation (IMV) remains a key goal of intensive care practice. The use of non-invasive ventilation (NIV) as a weaning strategy (transitioning patients who are difficult to wean to early NIV) may reduce mortality, ventilator-associated pneumonia and intensive care unit (ICU) length of stay. Objectives Our objectives were to determine the cost effectiveness of protocolised weaning, including early extubation onto NIV, compared with weaning without NIV in a UK National Health Service setting. Methods We conducted an economic evaluation alongside a multicentre randomised controlled trial. Patients were randomised to either protocol-directed weaning from mechanical ventilation or ongoing IMV with daily spontaneous breathing trials. The primary efficacy outcome was time to liberation from ventilation. Bivariate regression of costs and quality-adjusted life-years (QALYs) provided estimates of the incremental cost per QALY and incremental net monetary benefit (INMB) overall and for subgroups [presence/absence of chronic obstructive pulmonary disease (COPD) and operative status]. Long-term cost effectiveness was determined through extrapolation of survival curves using flexible parametric modelling. Results NIV was associated with a mean INMB of £620 ($US885) (cost-effectiveness threshold of £20,000 per QALY) with a corresponding probability of 58$US6594 per QALY gained). Conclusions The probability of NIV being cost effective relative to weaning without NIV ranged between 57 and 59% overall and between 82 and 87% for the COPD subgroup

Cardiac amyloidosis in non-transplant cardiac surgery

Cardiac amyloidosis is a rare infiltrative cardiomyopathy that portends a poor prognosis. There is a growing recognition of co-existent aortic valve stenosis and transthyretin cardiac amyloidosis, with some studies suggesting that dual pathology may be associated increased risk of complication and mortality during surgical intervention. This review aims to evaluate the available literature on non-transplant cardiac surgical interventions in patients with cardiac amyloidosis, with particular focus on diagnosis, high surgical risk and areas of uncertainty that require further research

Ideas to Action: Using Curriculum Design to Develop a “Roadmap to Wellness” Curriculum

Introduction: Physician burnout, well-being, and professional fulfillment are deeply intertwined topics that are increasingly recognized as affecting the lives of physicians, health care workers, and patients alike. The Accreditation Council for Graduate Medical Education (ACGME) mandates that all residencies address wellness within the context of residency training without providing much guidance on how to do so. Emergency Medicine organizations such as the American College of Emergency Physicians, the American Academy of Emergency Physicians, the Society for Academic Emergency Medicine, and the Council of Residency Directors of Emergency Medicine (CORD) suggest that one method to address wellness is in the form of a curriculum. Successfully developing or modifying a curriculum to work for individual residency programs can be a difficult task. Methods: The CORD Resilience Committee Wellness Curriculum Subcommittee comprised of experts in physician wellness and medical education started by conducted literature searches on terms related to burnout and wellness and searching the internet for documented wellness curricula, models and resources. Using this information and a standard curriculum development process, they created a roadmap for developing (or modifying), initiating, and evaluating a wellness curriculum. Conclusion: Wellness curricula are not a one-size-fits-all situation. Using the checklist and guidelines in this white paper, readers can individualize existing wellness curricula to help foster physician well-being

A Resident Retreat with Emergency Medicine Specific Mindfulness Training Significantly Reduces Burnout and Perceived Stress

Introduction: We hypothesize that a resident retreat with mindfulness training tailored for Emergency Medicine (EM) physicians can significantly reduce levels of burnout and perceived stress in EM residents. Methods: We conducted an intervention study of 60 EM residents undergoing an annual resident retreat with a 2.5-hour mindfulness training. The retreat was a department-funded 2-day off-site experience with a wellness theme. The training was developed and delivered by an EM physician (JO\u27S) who is a Mindfulness-Based Stress Reduction (MBSR) teacher trainee, and a certified MBSR teacher (MD). The training focused on techniques that can be used on shift, such as mindful breathing, handwashing, eating/drinking, walking, and anchoring before resuscitations. The cohort contained an equal distribution of 1st, 2nd and 3rd year residents who received a financial incentive. The subjects completed the Maslach Burnout Inventory, Perceived Stress Scale and Mindful Attention and Awareness Scale at three time points: Time 1 - one month prior, Time 2 – one week post, Time 3 – one month post. Results: The subjects were 60 EM residents (54% Male, 46% Female) with an average age of 29. Completion rates at the three time points were 70% (n = 42), 60% (n = 36) and 50% (n = 30) respectively. We found that Perceived Stress (ω2 = 0.15, p \u3c 0.01) and Emotional Exhaustion (ω2 = 0.21, p \u3c 0.01) decreased significantly over time in a linear progression across the three sampling periods. Though mindfulness as a trait did not change significantly during the study period, in the month after the retreat, 64% of resident respondents at Time 3 (n = 32) reported using the mindfulness techniques learned from the training at least 2 or 3 times a week on shift and 52% (n = 31) reported using them at least 2 or 3 times a week at home. Conclusions: An EM resident retreat that included an EM specific mindfulness training significantly reduced perceived stress and emotional exhaustion. The learned mindfulness skills were readily adopted for use on shift. Further studies should investigate effectiveness of mindfulness training outside of the retreat format. Other wellness / academic activities that occur within the socially supportive milieu of a retreat could lead to the same significant reduction in burnout and perceived stress seen in the current study

Development of Mountain Climate Generator and Snowpack Model for Erosion Predictions in the Western United States Using WEPP: Phase IV

Executive Summary: Introduction: This report summarizes work conducted during the funding period (December 1, 1991 through September 30, 1992) of a Research Joint Venture Agreement between the Intermountain Research Station, Forest Service, U. S. Department of Agriculture and the Utah Water Research Laboratory (UWRL), Utah State University (USU). The purpose of the agreement is to develop a Western Mountain Cilmate Generator (MCLIGEN) similar in function to the existing (non-orographic area) Climate Generator (CLIGEN), which is part of the Water Erosion Prediciton Project (WEPP) procedure. Aso, we are developing a Western U.S. Snowpack Simulation Model for includsion in WEPP. In the western U.S., topographic influences on climate make the climate too variable to be captured by one representatbie station per 100 km, as is done in CLIGEN. Also, few meteorological observations exist in high-elevation areas where Forest Service properties are located. Therefore, a procedure for estimating climatological variables in mountainous areas is needed to apply WEPP in these regions. A physically based approach, using an expanded and improved orographic precipitation model, is being utilized. It will use radiosonde lightning data to estimate historical weather sequences. Climatological sequences estimated at ungaged locations will be represented using stochastic models, similar to the approach used in the existing CLIGEN. By using these stochastic models, WEPP users will be able to synthesize climate sequences for input to WEPP. MCLIGEN will depend on historically based, physically interpolated weather sequences from a mesoscale-climate modeling system which is comprised of four nested layers: 1. an existing synoptic scale forecast model (200 x 300 km) 2. a regional scale slimate model (60 x60 km) 3. a local scale climate model (10 x 10 km); and 4. a specific point climate predictor, referred to as ZOOM. Two additional MCLIGEN components are: 5. a local scalses stochastic climate generator; and 6. a point energy balance snowmelt model Progress made during the reporting period in developing the physically based interpolation climate modeling system stochastic models, and snowpack models is summareized below