Medical Student Milestones in Emergency Medicine

Objectives Medical education is a continuum from medical school through residency to unsupervised clinical practice. There has been a movement toward competency‐based medical education prompted by the Accreditation Council for Graduate Medical Education ( ACGME ) using milestones to assess competence. While implementation of milestones for residents sets specific standards for transition to internship, there exists a need for the development of competency‐based instruments to assess medical students as they progress toward internship. The objective of this study was to develop competency‐based milestones for fourth‐year medical students completing their emergency medicine ( EM ) clerkships (regardless of whether the students were planning on entering EM ) using a rigorous method to attain validity evidence. Methods A literature review was performed to develop a list of potential milestones. An expert panel, which included a medical student and 23 faculty members (four program directors, 16 clerkship directors, and five assistant deans) from 19 different institutions, came to consensus on these milestones through two rounds of a modified Delphi protocol. The Delphi technique builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Results Of the initial 39 milestones, 12 were removed at the end of round 1 due to low agreement on importance of the milestone or because of redundancy with other milestones. An additional 12 milestones were revised to improve clarity or eliminate redundancy, and one was added based on expert panelists' suggestions. Of the 28 milestones moving to round 2, consensus with a high level of agreement was achieved for 24. These were mapped to the ACGME EM residency milestone competency domains, as well as the Association of American Medical Colleges ( AAMC ) core entrustable professional activities for entering residency to improve content validity. Conclusions This study found consensus support by experts for a list of 24 milestones relevant to the assessment of fourth‐year medical student performance by the completion of their EM clerkships. The findings are useful for development of a valid method for assessing medical student performance as students approach residency. Resumen Objetivos La formación médica es un continuo que va desde la universidad, pasando por la residencia, hasta la práctica clínica no supervisada. Ha habido un movimiento hacia la formación médica basada en la adquisición de competencias promovido por el Accreditation Council for Graduate Medical Education ( ACGME ) mediante los hitos para evaluar la competencia. Mientras la implementación de los hitos para los residentes establece normas específicas para la transición a residente, existe necesidad de desarrollar instrumentos basados en la competencia para evaluar a los estudiantes de medicina según progresan hacia la residencia. El objetivo de este estudio fue desarrollar los hitos basados ​​en competencias para los estudiantes de medicina de cuarto año al completar sus prácticas clínicas en Medicina de Urgencias y Emergencias ( MUE ) (indistintamente si el estudiante planeaba acceder a la MUE ) utilizando un método riguroso para lograr evidencia válida. Metodología Se realizó una revisión de la literatura para desarrollar una lista de hitos potenciales. Un panel de expertos, que incluyó 23 profesores de la facultad cuyas responsabilidades eran directores de programa (4), directores de prácticas clínicas (16), vicedecanos (5) y un estudiante de medicina de 19 instituciones diferentes, llegaron a un consenso sobre estos hitos a través de 2 rondas del protocolo de Delphi modificado. La técnica Delphi construye un contenido válido y es un método aceptado para desarrollar un consenso mediante la obtención de opiniones de expertos a través de múltiples rondas de preguntas. Resultados De los 39 hitos iniciales, se eliminaron 12 al final de la primera ronda debido al bajo acuerdo sobre la importancia del hito o debido a su redundancia con otros hitos. Se revisaron 12 hitos adicionales para mejorar la claridad o eliminar la redundancia, y se añadió uno basado en las sugerencias del panel de expertos. De los 28 hitos que llegaron a la segunda ronda, se alcanzó un consenso con un alto nivel de acuerdo para 24 de los hitos. Estos hitos se esquematizaron a los dominios de competencia de los hitos de la residencia de MUE del ACGME , así como a las actividades profesionales recomendadas para acceder a la residencia de la Association of American Medical Colleges ( AAMC ) para mejorar la validez de contenido. Conclusiones Este estudio llegó a un consenso apoyado por expertos para una lista de 24 hitos relevantes para evaluar el rendimiento de los estudiantes de medicina de cuarto año al finalizar su práctica clínica en MUE . Los hallazgos son útiles para el desarrollo de un método válido para evaluar el rendimiento de los estudiantes de medicina a medida que éstos se acercan a la residencia.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/108261/1/acem12443-sup-0002-DataSupplementS2.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/108261/2/acem12443.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/108261/3/acem12443-sup-0001-DataSupplementS1.pd

Bimodal release ondansetron for acute gastroenteritis among adolescents and adults: A randomized clinical trial

Importance: Vomiting resulting from acute gastroenteritis is commonly treated with intravenous antiemetics in acute care settings. If oral treatment were beneficial, patients might not need intravenous administered hydration or medication. Furthermore, a long-acting treatment could provide sustained relief from nausea and vomiting. Objective: To determine whether an experimental long-acting bimodal release ondansetron tablet decreases gastroenteritis-related vomiting and eliminates the need for intravenous therapy for 24 hours after administration. Design, Setting, and Participants: This placebo-controlled, double-blind, randomized clinical trial included patients from 19 emergency departments and 2 urgent care centers in the United States from December 8, 2014, to February 17, 2017. Patients 12 years and older with at least 2 vomiting episodes from presumed gastroenteritis in the previous 4 hours and symptoms with less than 36 hours\u27 duration were randomized using a 3:2 active to placebo ratio. Analyses were performed on an intent-to-treat basis and conducted from June 1, 2017, to November 1, 2017. Intervention: Bimodal release ondansetron tablet containing 6 mg of immediate release ondansetron and 18 mg of a 24-hour release matrix for a total of 24 mg of ondansetron. Main Outcomes and Measures: Treatment success was defined as no further vomiting, no need for rescue medication, and no intravenous hydration for 24 hours after bimodal release ondansetron administration. Results: Analysis included 321 patients (mean [SD] age, 29.0 [11.1] years; 195 [60.7%] women), with 192 patients in the bimodal release ondansetron group and 129 patients in the placebo group. Treatment successes were observed in 126 patients in the bimodal release ondansetron group (65.6%) compared with 70 patients in the placebo group (54.3%), with an 11.4% (95% CI, 0.3%-22.4%) absolute probability difference. The proportion of treatment success was 21% higher among patients who received bimodal release ondansetron compared with those who received a placebo (relative risk, 1.21; 95% CI, 1.00-1.46; P = .04). In an analysis including only patients with a discharge diagnosis of acute gastroenteritis and no major protocol violations, there were 123 treatment successes (69.5%) in the bimodal release ondansetron group compared with 67 treatment successes (54.9%) in the placebo group (relative risk, 1.27; 95% CI, 1.05-1.53; P = .01). Adverse effects were infrequent and similar to the known safety profile of ondansetron. Conclusions and Relevance: This randomized clinical trial found that a long-acting bimodal release oral ondansetron tablet was an effective antiemetic among adolescents and adults with moderate to severe vomiting from acute gastroenteritis. The drug benefits extended to 24 hours after administration. Bimodal release ondansetron may decrease the need for intravenous access and emergency department care to manage acute gastroenteritis. Trial Registration: ClinicalTrials.gov identifier: NCT02246439

In Crisis: Medical Students in the COVID‐19 Pandemic

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/156130/2/aet210450.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156130/1/aet210450_am.pd

Zooming In Versus Flying Out: Virtual Residency Interviews in the Era of COVID‐19

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163370/2/aet210486.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163370/1/aet210486_am.pd

The National Clinical Assessment Tool for Medical Students in the Emergency Department (NCAT-EM)

Introduction: Clinical assessment of medical students in emergency medicine (EM) clerkships is a highly variable process that presents unique challenges and opportunities. Currently, clerkship directors use institution-specific tools with unproven validity and reliability that may or may not address competencies valued most highly in the EM setting. Standardization of assessment practices and development of a common, valid, specialty-specific tool would benefit EM educators and students. Methods: A two-day national consensus conference was held in March 2016 in the Clerkship Directors in Emergency Medicine (CDEM) track at the Council of Residency Directors in Emergency Medicine (CORD) Academic Assembly in Nashville, TN. The goal of this conference was to standardize assessment practices and to create a national clinical assessment tool for use in EM clerkships across the country. Conference leaders synthesized the literature, articulated major themes and questions pertinent to clinical assessment of students in EM, clarified the issues, and outlined the consensus- building process prior to consensus-building activities. Results: The first day of the conference was dedicated to developing consensus on these key themes in clinical assessment. The second day of the conference was dedicated to discussing and voting on proposed domains to be included in the national clinical assessment tool. A modified Delphi process was initiated after the conference to reconcile questions and items that did not reach an a priori level of consensus. Conclusion: The final tool, the National Clinical Assessment Tool for Medical Students in Emergency Medicine (NCAT-EM) is presented here. [West J Emerg Med. 2018;19(1)66-74.

Utility of COVID-19 antigen testing in the emergency department

Background: The BinaxNOW coronavirus disease 2019 (COVID-19) Ag Card test (Abbott Diagnostics Scarborough, Inc.) is a lateral flow immunochromatographic point-of-care test for the qualitative detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleocapsid protein antigen. It provides results from nasal swabs in 15 minutes. Our purpose was to determine its sensitivity and specificity for a COVID-19 diagnosis. Methods: Eligible patients had symptoms of COVID-19 or suspected exposure. After consent, 2 nasal swabs were collected; 1 was tested using the Abbott RealTime SARS-CoV-2 (ie, the gold standard polymerase chain reaction test) and the second run on the BinaxNOW point of care platform by emergency department staff. Results: From July 20 to October 28, 2020, 767 patients were enrolled, of which 735 had evaluable samples. Their mean (SD) age was 46.8 (16.6) years, and 422 (57.4%) were women. A total of 623 (84.8%) patients had COVID-19 symptoms, most commonly shortness of breath (n = 404; 55.0%), cough (n = 314; 42.7%), and fever (n = 253; 34.4%). Although 460 (62.6%) had symptoms ≤7 days, the mean (SD) time since symptom onset was 8.1 (14.0) days. Positive tests occurred in 173 (23.5%) and 141 (19.2%) with the gold standard versus BinaxNOW test, respectively. Those with symptoms \u3e2 weeks had a positive test rate roughly half of those with earlier presentations. In patients with symptoms ≤7 days, the sensitivity, specificity, and negative and positive predictive values for the BinaxNOW test were 84.6%, 98.5%, 94.9%, and 95.2%, respectively. Conclusions: The BinaxNOW point-of-care test has good sensitivity and excellent specificity for the detection of COVID-19. We recommend using the BinasNOW for patients with symptoms up to 2 weeks

Mosque-based emotional support among young Muslim Americans

Despite a growing literature on social support networks in religious settings (i.e., church-based social support), little is known about mosque-based support among Muslims. This study investigates the demographic and religious behavior correlates of mosque-based social support among a multi-racial and ethnic sample of 231 young Muslims from southeast Michigan. Several dimensions of mosque-based support are examined including receiving emotional support, giving emotional support, anticipated emotional support and negative interactions with members of one’s mosque. Results indicated that women both received and antic- ipated receiving greater support than did men. Higher educational attainment was associated with receiving and giving less support compared to those with the lowest level of educational attainment. Moreover, highly educated members reported fewer negative interactions than less educated members. Mosque attendance and level of congregational involvement positively predicted receiving, giving, and anticipated emotional support from congregants, but was unrelated to negative interactions. Overall, the study results converge with previously established correlates of church- based emotional support.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/107410/1/art%3A10.1007%2Fs13644-013-0119-0(1).pd

Resilience, redundancy and low-carbon living: co-producing individual and community learning

There is an acknowledged need for buildings and communities to be more resilient in the face of unpredictable effects of climate change, economic crises and energy supplies. The notion and social practices involving redundancy (the ability to switch between numerous available choices beyond optimal design) are explored as an aspect of resilience theory. Practice and Social Learning theories are used as a lens through which to explore the available redundancy in housing and home environments to help prevent performance failure through unexpected circumstances or in response to varying user needs. Findings from an in depth UK housing case study show how redundancy is linked with the capacity to share resources and to learn both individually and collectively as a community. Such learning in relation to resilient low-carbon living is shown to be co-produced effectively through participatory action research. The benefits of introducing extra redundancy in housing design and community development to accommodate varied user’s understanding and preferences are discussed in relation to future proofing, value and scalar issues. Recommendations include better understanding of the design, time and monetary contribution needed to implement social or technical redundancy. These costs should be evaluated in context of savings made through greater resilience achieved

Curriculum in early childhood education: critical questions about content, coherence, and control

A continuing struggle over curriculum in early childhood education is evident in contemporary research and debate at national and international levels. This reflects the dominant influence of developmental psychology in international discourses, and in policy frameworks that determine approaches to curriculum, pedagogy, and assessment. Focusing on early childhood education, we argue that this struggle generates critical questions about three significant themes within curriculum theory: content, coherence, and control. We outline two positions from which these themes can be understood: Developmental and Educational Psychology and contemporary policy frameworks. We argue that within and between these positions, curriculum content, coherence, and control are viewed in different and sometimes oppositional ways. Following this analysis, we propose that a focus on ‘working theories’ as a third position offers possibilities for addressing some of these continuing struggles, by exploring different implications for how content, coherence, and control might be understood. We conclude that asking critical questions of curriculum in early childhood education is a necessary endeavour to develop alternative theoretical frameworks for understanding the ways in which curriculum can be considered alongside pedagogy, assessment, play, and learning

Predictors of mortality among elderly people living in a south Indian urban community; a 10/66 Dementia Research Group prospective population-based cohort study

<p>Abstract</p> <p>Background</p> <p>Eighty percent of deaths occur in low and middle income countries (LMIC), where chronic diseases are the leading cause. Most of these deaths are of older people, but there is little information on the extent, pattern and predictors of their mortality. We studied these among people aged 65 years and over living in urban catchment areas in Chennai, south India.</p> <p>Methods</p> <p>In a prospective population cohort study, 1005 participants were followed-up after three years. Baseline assessment included sociodemographic and socioeconomic characteristics, health behaviours, physical, mental and cognitive disorders, disability and subjective global health.</p> <p>Results</p> <p>At follow-up, 257 (25.6%) were not traced. Baseline characteristics were similar to the 748 whose vital status was ascertained; 154 (20.6%) had died. The mortality rate was 92.5/1000 per annum for men and 51.0/1000 per annum for women. Adjusting for age and sex, mortality was associated with older age, male sex, having no friends, physical inactivity, smaller arm circumference, dementia, depression, poor self-rated health and disability. A parsimonious model included, in order of aetiologic force, male sex, smaller arm circumference, age, disability, and dementia. The total population attributable risk fraction was 0.90.</p> <p>Conclusion</p> <p>A balanced approach to prevention of chronic disease deaths requires some attention to proximal risk factors in older people. Smoking and obesity seem much less relevant than in younger people. Undernutrition is preventable. While dementia makes the largest contribution to disability and dependency, comorbidity is the rule, and more attention should be given to the chronic care needs of those affected, and their carers.</p