Curriculum Development: Foundations and Modern Advances in Graduate Medical Education

Curriculum development has undergone many transitions since the inception of medical education in the United States in the 1800’s. In this chapter, we briefly review the history of curriculum development in medical education. We discuss the landmark models of curriculum development including the concept of a curriculum map and Harden’s SPICES model of educational strategy, detail the six steps of Kern’s foundational framework, and provide an overview of the PRISMS strategy. We address the importance of adult learning theory and the advancing understanding of education for the millennial generation, including implementation of the flipped classroom model of education. Finally, we turn our focus on contemporary applications of curriculum design, including the application of simulation to medical education, the rise of massive open online courses (MOOC), and the implementation of free open access medical education (FOAM) within undergraduate and graduate medical curricula

Demographics, Activities, and Environmental Factors Impact Burnout in a National Survey of Emergency Medicine Residents

Introduction: Burnout in emergency medicine and in residency training has been well-described. The impact of demographic, individual, and programmatic factors on burnout have not previously been determined in a national survey of emergency medicine residents. This study aimed to identify personal and environmental factors impacting resident burnout in a national sample of emergency medicine residents. Methods: A prospective Emergency Medicine Resident Wellness Survey was administered in 2017. We surveyed respondents on demographic, personal, and environmental factors; each respondent also completed the Maslach Burnout Inventory - Human Services Survey. Linear regressions were used to identify variables associated with the Maslach Burnout Inventory’s subscales of burnout (depersonalization, emotional exhaustion, and personal achievement). Results: The survey was completed by 1,522 of 7,186 (21.2%) eligible EM residents. Respondents represented 193 of 247 (78.1%) Emergency Medicine residency programs. Increased levels of depersonalization were associated with graduation from a US medical school, female gender, and increase in respondent age. Trainees who were parents and who graduated from an osteopathic (vs. allopathic) medical school were found to have decreased levels of depersonalization. Emotional exhaustion was decreased in respondents who took breaks while on shift and who engaged in regular studying. Conclusion: While some individual characteristics impact burnout, environmental factors also play a significant role, and should be a target of system-level interventions to improve trainee well-being

Factor Structure and Measurement Invariance of the Maslach Burnout Inventory in Emergency Medicine Residents

Introduction: Emergency medicine residents suffer from high rates of occupational burnout. Recent research has focused on identifying risk and protective factors for burnout as well as targets for intervention. This research has primarily employed the Maslach Burnout Inventory to evaluate burnout in this population. Factor analytic work has identified three underlying factors measured by the Maslach Burnout Inventory: Emotional Exhaustion, Depersonalization, and Personal Accomplishment. However, this three-factor structure has not been evaluated in emergency medicine residents. Furthermore, its structural equivalence has not been demonstrated across commonly-studied risk factors, such as gender and year of post-graduate training. In the present study, we evaluated the structure of the Maslach Burnout Inventory in emergency medicine residents as well as its measurement invariance across gender and post-graduate year. Methods: 1522 emergency medicine residents (21.1% of all US residents from 78.1% of US residency programs) were recruited as part of the 2017 National EM Resident Wellness Survey and completed the Maslach Burnout Inventory – Human Services Survey. The factor structure and measurement invariance across both respondent gender and post-graduate year were evaluated using a series of confirmatory factor analyses. Exploratory analyses evaluated whether burnout scores differed across men/women and post-graduate years 1, 2, and 3+ using a structural equation model. Results: The three-factor structure was observed after minor modifications which replicated in cross-validation. This structure was invariant across both gender and post-graduate year at the configural, metric, and scalar levels. Emotional exhaustion scores were higher for female residents and scores on all of the MBI scales indicated greater burnout for more advanced residents. Conclusions: These results indicate the Maslach Burnout Inventory is fully structurally equivalent across gender and post-graduate year and further validates its use in this population. Secondary evaluations of the latent means revealed that female residents tend to have higher scores on Emotional Exhaustion and that scores on all factors tend to worsen as trainees progress through their residency

A 2-Question Summative Score Correlates with the Maslach Burnout Inventory

Introduction: There is a high prevalence of burnout among emergency medicine (EM) residents. The Maslach Burnout Inventory - Human Services Survey (MBI-HSS) is a widely used tool to measure burnout. The objective of this study was to compare the MBI-HSS and a two-question tool to determine burnout in the EM resident population.Methods: Based on data from the 2017 National Emergency Medicine Resident Wellness Survey study, we determined the correlation between two single-item questions with their respective MBI subscales and the full MBI-HSS. We then compared a 2-Question Summative Score to the full MBI-HSS with respect to primary, more restrictive, and more inclusive definitions of burnout previously reported in the literature.Results: Of 1,522 residents who completed the survey 37.0% reported “I feel burned out from my work,” and 47.1% reported “I have become more callous toward people since I took this job” once a week or more (each item >3 on a scale of 0-6). A 2-Question Summative Score totaling >3 correlated most closely with the primary definition of burnout (Spearman’s rho 0.65 [95% confidence interval 0.62-0.68]). Using the summative score, 77.7% of residents were identified as burned out, compared to 76.1% using the full MBI-HSS, with a sensitivity and specificity of 93.6% and 73.0%, respectively.Conclusion: An abbreviated 2-Question Summative Score correlates well with the full MBI-HSS tool in assessing EM resident physician burnout and could be considered a rapid screening tool to identify at-risk residents experiencing burnout

Optimist Prime- Emergency Medicine Residents are an Optimistic Group

Introduction: No study before has been conducted looking at the level of optimism and pessimism in emergency medicine residents and how it may be linked to resident burnout. This is the first national- level assessment of these personality factors. Methods: This was a prospective survey study leveraging data obtained through the 2017 National Emergency Medicine Resident Wellness Survey, which included the Life Orientation Test-Revised (LOT-R). The Life Orientation Test-Revised (LOT-R) is a 10-item tool that measures levels of optimism versus pessimism. Results: We found that the majority of our resident respondents scored in the moderate category of the LOT-R. Additionally, 12.4% fell into the more optimistic category. Conclusion: The results indicate that emergency medicine residents are not generally pessimistic and a pessimistic outlook is unlikely to affect resident levels of fatigue, burnout or emotional distress

More Work, Less Reward: The Minority Tax on US Medical Students

Introduction: Minority tax is defined as the burden of time and resources placed on minority persons to represent and advocate for their communities. We determined whether medical students underrepresented in medicine (URM) or from historically excluded (HE) populations experience a minority tax and characterized its effects. Methods: This cross-sectional survey of US medical students occurred November 2020 - June 2021. We used Mann-Whitney U tests to compare metrics between URM and HE participants and their peers. The primary outcome was time invested in activism/diversity initiatives versus other work. Secondary outcomes included measures of microaggressions, discrimination, institutional culture, anxiety/depression, mentorship, and sleep. We performed thematic analysis of open-ended questions about participants’ experiences with minority tax. Results: A total 282 students included 39 (13.8%) URM and 150 (53.9%) HE participants. Compared to peers, URM and HE participants invested an additional 36.4 (p = 0.005) and 46.8 (p = 0.006) annual hours on advocacy and 62.4 (p \u3c 0.001) and 41.6 (p = 0.001) annual hours on diversity initiatives, respectively. URM and HE participants reported more microaggressions / discrimination, less inclusive environments, and no differences in access to mentorship or sleep. Six themes were evident: (1) URM and HE students feel obligated to do diversity, equity, and inclusion (DEI) work, (2) students doing DEI work experience minority tax, (3) minority tax is negatively associated with wellness, (4) learning environment changes may mitigate minority tax, (5) there is a demand for increased representation and improved DEI education, and (6) an increased DEI budget might reduce the minority tax for students. Conclusion: URM and HE medical students experience a minority tax that may affect their wellbeing. These findings should serve as a call for action by medical school leaders

How Well Do Core Faculty Understand The Emergency Medicine Milestones?

Introduction: It is unclear how emergency medicine (EM) programs educate core faculty about the use of milestones in competency-based evaluations. We conducted a national survey to profile how programs educate core faculty regarding their use and to assess core faculty’s understanding of the milestones.Methods: Our survey tool was distributed over six months in 2017 via the Council of Emergency Medicine Residency Directors (CORD) listserv. Responses, which were de-identified, were solicited from program directors (PDs), assistant/associate program directors (APDs), and core faculty. A single response from a program was considered sufficient.Results: Our survey had a 69.7% response rate (n=140/201). 62.9% of programs reported educating core faculty about the EM Milestones via the distribution of physical or electronic media. Although 82.6% of respondents indicated that it was important for core faculty to understand how the EM Milestones are used in competency-based evaluations, respondents estimated that 48.6% of core faculty possess “fair or poor” understanding of the milestones. Furthermore, only 50.7% of respondents felt that the EM Milestones were a valuable tool.Conclusion: These data suggest there is sub-optimal understanding of the EM Milestones among core faculty and disagreement as to whether the milestones are a valuable tool

How Well Do Core Faculty Understand The Emergency Medicine Milestones?

Introduction: It is unclear how emergency medicine (EM) programs educate core faculty about the use of milestones in competency-based evaluations. We conducted a national survey to profile how programs educate core faculty regarding their use and to assess core faculty’s understanding of the milestones.Methods: Our survey tool was distributed over six months in 2017 via the Council of Emergency Medicine Residency Directors (CORD) listserv. Responses, which were de-identified, were solicited from program directors (PDs), assistant/associate program directors (APDs), and core faculty. A single response from a program was considered sufficient.Results: Our survey had a 69.7% response rate (n=140/201). 62.9% of programs reported educating core faculty about the EM Milestones via the distribution of physical or electronic media. Although 82.6% of respondents indicated that it was important for core faculty to understand how the EM Milestones are used in competency-based evaluations, respondents estimated that 48.6% of core faculty possess “fair or poor” understanding of the milestones. Furthermore, only 50.7% of respondents felt that the EM Milestones were a valuable tool.Conclusion: These data suggest there is sub-optimal understanding of the EM Milestones among core faculty and disagreement as to whether the milestones are a valuable tool

Leveraging Resources to Remove a Taser Barb Embedded in Bone: Case Report

Introduction: Conducted electrical weapons, commonly known by their proprietary eponym, TASER, are frequently used by law enforcement. A review of the literature yielded descriptions of taser barb removal from soft tissue and surgical intervention for barbs lodged in sensitive areas such as the eye and head, but not from other osseous sites.Case Report: We report the case of a 30-year-old male transferred from another hospital with a taser dart embedded in his clavicle. Prior attempts at bedside removal had been unsuccessful. We describe bedside removal of the taser barb from bone using local anesthesia and simple fulcrum technique.Conclusion: We describe a novel fulcrum technique for removal of a taser dart embedded in bone. This is a reasonable technique to attempt in patients with involvement of superficial osseous structures to avoid operative intervention