Feedback in the Emergency Medicine Clerkship

Objective: Feedback is a technique used in medical education to help develop and improve clinical skills. A comprehensive review article specifically intended for the emergency medicine (EM) educator is lacking, and it is the intent of this article to provide the reader with an in-depth, up-to-date, and evidence-based review of feedback in the context of the EM clerkship. Methods: The review article is organized in a progressive manner, beginning with the definition of feedback, the importance of feedback in medical education, and the obstacles limiting the effective delivery of feedback, and the techniques to overcome these obstacles then follows. The article concludes with practical recommendations to implement feedback in the EM clerkship. To advance the literature on feedback, the concept of receiving feedback is introduced. Results: The published literature regarding feedback is limited but generally supportive of its importance and effectiveness. Obstacles in the way of feedback include time constraints, lack of direct observation, and fear of negative emotional responses from students. Feedback should be timely, expected, focused, based on first-hand data, and limited to behaviors that are remediable. Faculty development and course structure can improve feedback in the EM clerkship. Teaching students to receive feedback is a novel educational technique that can improve the feedback process. Conclusion: Feedback is an important educational technique necessary to improve clinical skills. Feedback can be delivered effectively in the EM clerkship. [West J Emerg Med. 2011;12(4):537–542.]</p

Are all competencies equal in the eyes of residents? A multicenter study of emergency medicine residents’ interest in feedback

Introduction: Feedback, particularly real-time feedback, is critical to resident education.  The emergency medicine (EM) milestones were developed in 2012 to enhance resident assessment and many programs utilize them to provide focused resident feedback. The purpose of this study was to evaluate EM residents’ level of interest in receiving real-time feedback on each of the 23 milestone sub-competencies.Methods: This was a multicenter cross sectional study of EM residents. Participants were surveyed on their level of interest in receiving real-time on-shift feedback on each of the 23 milestone sub-competencies. Anonymous paper or computerized surveys were distributed to residents at three 4-year training programs and three 3-year training programs with a total of 223 resident respondents. Residents rated their level of interest in each milestone on a 6-point semantic differential response scale. Average level of interest was calculated for each of the 23 sub-competencies, both as an average of all 223 respondents as well as by individual postgraduate year (PGY) level of training. One-way ANOVA analysis was performed to determine statistical significance.Results: The overall survey response rate across all institutions was 82%. Emergency stabilization had the highest mean rating (5.47/6) while technology had the lowest rating (3.24/6). However, none of the 23 milestone sub-competencies were statistically significant based on ANOVA analysis.Conclusion: It is unclear whether residents ascribe much more value to certain sub-competency domains than others.  Further studies are necessary to determine whether residents’ sub-competency valuations need to be considered when developing an assessment or feedback program focusing on the 23 EM milestones

How Competent Are Emergency Medicine Interns for Level 1 Milestones: Who Is Responsible?

Objectives The Next Accreditation System ( NAS ) of the Accreditation Council for Graduate Medical Education ( ACGME ) includes the implementation of developmental milestones for each specialty. The milestones include five progressively advancing skill levels, with Level 1 defining the skill level of a medical student graduate, and Level 5, that of an attending physician. The goal of this study was to query interns on how well they thought their medical school had prepared them to meet the proposed emergency medicine ( EM ) Level 1 milestones. Methods In July 2012, an electronic survey was distributed to the interns of 13 EM residency programs, asking interns whether they were taught and assessed on the proposed Level 1 milestones. Results Of possible participants, 113 of 161 interns responded (70% response rate). The interns represented all four regions of the country. The interns responded that the rates of Level 1 milestones they had been taught ranged from 61% for ultrasound to 98% for performance of focused history and physical examination. A substantial number of interns (up to 39%) reported no instruction on milestones such as patient disposition, pain management, and vascular access. Graduating medical students were less commonly assessed than taught the milestones. Skills with technology, including “explain the role of the electronic health record and computerized physician order entry,” were assessed for only 39% of interns, and knowledge ( USMLE ) and history and physical were assessed in nearly all interns. Disposition, ultrasound, multitasking, and wound management were assessed less than half of the time. Conclusions Many entering EM interns may not have had either teaching or assessment on the knowledge, skills, and behaviors making up the Level 1 milestones expected for graduating medical students. Thus, there is a potential gap in the teaching and assessment of EM interns. Based on these findings, it is unclear who will be responsible (medical schools, EM clerkships, or residency programs) for ensuring that medical students entering residency have achieved Level 1 milestones. Resumen Competencia de los Residentes de Medicina de Urgencias y Emergencias para el Nivel 1: ¿Quién es el Responsable? El próximo sistema de acreditación ( NAS , Next Accreditation System ) del Accreditation Council for Graduate Medical Education ( ACGME ) incluye la implementación de objetivos por área de desarrollo para cada especialidad. Los objetivos por área incluyen cinco niveles de habilidades progresivamente avanzadas, con un nivel 1 definido por el nivel de habilidad de un estudiante licenciado de medicina, y un nivel definido por el nivel, de un médico adjunto. El objetivo de este estudio fue preguntar a los residentes cómo pensaban que sus universidades les habían preparado para alcanzar los objetivos por área de nivel 1 propuestos en medicina de urgencias y emergencias ( MUE ). Metodología En julio de 2012, se distribuyó una encuesta electrónica a los residentes de 13 programas de residencia de MUE , preguntándoles si estaban formados y evaluados en los objetivos por área de nivel 1 propuestos. Resultados De los posibles participantes, 113 de 161 residentes (70%) respondieron. Los residentes representaban las cuatro regiones del país. Los residentes respondieron que los porcentajes de objetivos por área de nivel 1 en los que se habían formado variaron del 61% para la ecografía al 98% para la realización de la historia clínica y la exploración física. Un número importante de residentes (hasta un 39%) respondieron no formarse en objetivos por áreas tales como la ubicación del paciente, el manejo del dolor y el acceso vascular. Los estudiantes licenciados de medicina fueron menos frecuentemente evaluados que formados en los objetivos por área. Las habilidades con la tecnología, incluyendo la explicación del rol de la historia clínica electrónica y la solicitud de órdenes médicas computarizadas, se evaluaron sólo en el 39% de los residentes y el conocimiento ( USMLE , United States Medical Licensing Examination ) y la historia clínica y exploración física se evaluaron en casi todos los residentes. Es más, la ubicación, la ecografía, la multitarea y el manejo de heridas se evaluaron en menos de la mitad de las ocasiones. Conclusiones Muchos de los residentes que se inician en MUE pueden no haber tenido formación o evaluación en el conocimiento, las habilidades y los comportamientos preparatorios para los objetivos por área de nivel 1 esperados para los estudiantes licenciados de medicina. Además, hay una brecha potencial en la formación y la evaluación de los residentes de MUE . En base a estos hallazgos, no está claro quién será el responsable, las facultades de medicina, la administración de la MUE o los programas de residencia, para asegurar que los estudiantes de medicina que entren en la residencia hayan alcanzado los objetivos por área de nivel 1.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/99036/1/acem12162.pd

Advanced Topics in Emergency Medicine: Curriculum Development and Initial Evaluation

<p>Background: Emergency medicine (EM) is a young specialty and only recently has a recommended medical student curriculum been developed. Currently, many schools do not require students to complete a mandatory clerkship in EM, and if one is required, it is typically an overview of the specialty.</p> <p>Objectives: We developed a 10-month longitudinal elective to teach subject matter and skills in EM to fourth-year medical students interested in the specialty. Our goal was producing EM residents with the knowledge and skills to excel at the onset of their residency. We hoped to prove that students participating in this rigorous 10-month longitudinal EM elective would feel well prepared for residency.</p> <p>Methods: We studied the program with an end-of-the-year, Internet-based, comprehensive course evaluation completed by each participant of the first 2 years of the course. Graduates rated each of the course components by using a 5-point Likert format from ‘‘strongly disagree’’ to ‘‘strongly agree,’’ either in terms of whether the component was beneficial to them or whether the course expectations were appropriate, or their perceptions related to the course.</p> <p>Results: Graduates of this elective have reported feeling well prepared to start residency. The resident-led teaching shifts, Advanced Pediatric Life Support certification, Grand Rounds presentations, Advanced Cardiovascular Life Support proficiency testing, and ultrasound component, were found to be beneficial by all students.</p> <p>Conclusions: Our faculty believes that participating students will be better prepared for an EM residency than those students just completing a 1-month clerkship. Our data, although limited, lead us to believe that a longitudinal, immersion-type experience assists fourth-year medical students in preparation for residency. [West J Emerg Med. 2011;12(4):543–550.]</p

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

This Article Corrects: “Assessment of Physician Well-being, Part Two: Beyond Burnout”

Part One of this two-article series reviews assessment tools to measure burnout and other negative states. Physician well-being goes beyond merely the absence of burnout. Transient episodes of burnout are to be expected. Measuring burnout alone is shortsighted. Well-being includes being challenged, thriving, and achieving success in various aspects of personal and professional life. In this second part of the series, we identify and describe assessment tools related to wellness, quality of life, resilience, coping skills, and other positive states

Medical Student Professionalism Narratives: A Thematic Analysis and Interdisciplinary Comparative Investigation

<p>Abstract</p> <p>Background</p> <p>Professionalism development is influenced by the informal and hidden curriculum. The primary objective of this study was to better understand this experiential learning in the setting of the Emergency Department (ED). Secondarily, the study aimed to explore differences in the informal curriculum between Emergency Medicine (EM) and Internal Medicine (IM) clerkships.</p> <p>Methods</p> <p>A thematic analysis was conducted on 377 professionalism narratives from medical students completing a required EM clerkship from July 2008 through May 2010. The narratives were analyzed using established thematic categories from prior research as well as basic descriptive characteristics. Chi-square analysis was used to compare the frequency of thematic categories to prior research in IM. Finally, emerging themes not fully appreciated in the established thematic categories were created using grounded theory.</p> <p>Results</p> <p>Observations involving interactions between attending physician and patient were most abundant. The narratives were coded as positive 198 times, negative 128 times, and hybrid 37 times. The two most abundant narrative themes involved <it>manifesting respect </it>(36.9%) and <it>spending time </it>(23.7%). Both of these themes were statistically more likely to be noted by students on EM clerkships compared to IM clerkships. Finally, one new theme regarding <it>cynicism </it>emerged during analysis.</p> <p>Conclusions</p> <p>This analysis describes an informal curriculum that is diverse in themes. Student narratives suggest their clinical experiences to be influential on professionalism development. Medical students focus on different aspects of professionalism depending on clerkship specialty.</p

Feedback in the Emergency Medicine Clerkships

Objective: Feedback is a technique used in medical education to help develop and improve clinical skills. A comprehensive review article specifically intended for the emergency medicine (EM) educator is lacking, and it is the intent of this article to provide the reader with an in-depth, up-to-date, and evidence-based review of feedback in the context of the EM clerkship. Methods: The review article is organized in a progressive manner, beginning with the definition of feedback, the importance of feedback in medical education, and the obstacles limiting the effective delivery of feedback, and the techniques to overcome these obstacles then follows. The article concludes with practical recommendations to implement feedback in the EM clerkship. To advance the literature on feedback, the concept of receiving feedback is introduced. Results: The published literature regarding feedback is limited but generally supportive of its importance and effectiveness. Obstacles in the way of feedback include time constraints, lack of direct observation, and fear of negative emotional responses from students. Feedback should be timely, expected, focused, based on first-hand data, and limited to behaviors that are remediable. Faculty development and course structure can improve feedback in the EM clerkship. Teaching students to receive feedback is a novel educational technique that can improve the feedback process. Conclusion: Feedback is an important educational technique necessary to improve clinical skills. Feedback can be delivered effectively in the EM clerkship. [West J Emerg Med. 2011;12(4):537–542.]</p

Feedback in the Emergency Medicine Clerkships

Objective: Feedback is a technique used in medical education to help develop and improve clinical skills. A comprehensive review article specifically intended for the emergency medicine (EM) educator is lacking, and it is the intent of this article to provide the reader with an in-depth, up-to-date, and evidence-based review of feedback in the context of the EM clerkship. Methods: The review article is organized in a progressive manner, beginning with the definition of feedback, the importance of feedback in medical education, and the obstacles limiting the effective delivery of feedback, and the techniques to overcome these obstacles then follows. The article concludes with practical recommendations to implement feedback in the EM clerkship. To advance the literature on feedback, the concept of receiving feedback is introduced. Results: The published literature regarding feedback is limited but generally supportive of its importance and effectiveness. Obstacles in the way of feedback include time constraints, lack of direct observation, and fear of negative emotional responses from students. Feedback should be timely, expected, focused, based on first-hand data, and limited to behaviors that are remediable. Faculty development and course structure can improve feedback in the EM clerkship. Teaching students to receive feedback is a novel educational technique that can improve the feedback process. Conclusion: Feedback is an important educational technique necessary to improve clinical skills. Feedback can be delivered effectively in the EM clerkship. [West J Emerg Med. 2011;12(4):537–542.