This article essentially states that how the nation addresses ED crowding will define the future of EM. Currently, Emergency Departments are at a breaking point where overwhelming demands are commonly placed on under-resourced practices.
I’m working on writing a CORD consensus article on the impact of ED crowding on education and innovations towards maintaining educational excellence. We posited 2 scenarios of ED crowding:
- Overwhelming numbers of active ED patients
- Many ED boarders who are awaiting inpatient beds and who are taking up rooms which normally would have been used to see new patients
What approaches do you know of which improve the ED educational experience for learners? We have thus far categorized innovations into 3 areas:
“Medical Education in the United States and Canada in 1910” was a landmark article, published by Abraham Flexner (shown in photo) in 1910. It’s commonly referred to as the Flexner Report. It revolutionized medical education in its call for higher quality and standardization.
In summary the report advocated for the improvement of medical education and medical schools in 4 areas:
I need your help with a project!
My poster on blogging was accepted to the annual UCSF Academy of Medical Educator’s Education Day. Feelings of joy and validation were quickly followed by terror and inadequacy.
In order to get my poster costs reimbursed, I have to get feedback from my co-authors and incorporate that feedback into the poster. As you can see from the poster title on top, I have no co-authors! Since you are all my virtual co-authors, I thought I’d solicit for comments and suggestions.
“The effect of ED crowding on education”
My heart almost stopped when I read this article title in Amer J of Emerg Med. This was the premise of my recently completed study – using a prospective, time-motion methodology. I’m in the process of writing the manuscript. Did I get scooped by my friends at U Penn?
Whew. Fortunately, no. Different methodology.
This study was a cross-sectional study looking at learner assessment of education, using a validated tool called the ER (Emergency Rotation) Score. The results are interesting.
We know that ED crowding negatively impacts clinical care. How does it impact our teaching of medical students and residents? The ED is traditionally known as a great place for learning how to resuscitate high-acuity patients, to manage and risk-stratify undifferentiated cases, and to perform procedures. Experientially, I feel like I teach less when it gets extremely crowded.
Over a 5-week period, 43 residents and 3 medical students prospectively assessed 34 attendings using a simple ER Score tool. There were 352 separate encounters. This validated tool assessed the attending based on 4 domains (teaching, clinical care, approachability, helpfulness) with each domain assessed on a 5-point scale. The scores were correlated with crowding measures (waiting room number, occupancy rate, number of admitted patients, and patient-hours).
ER Score tool
What was their enrollment scheme?
Upon arrival, the research assistant selected the patient with the most recent admission order where the learner-attending pair was still present in the ED. The learner was asked to fill out the ER Score tool. For each admitted patient case, the research assistant also enrolled a non-admitted patient with a similar triage intake time. The learner for this non-admitted case was also asked to fill out the ER Score tool. The study group intentionally structured this methodology to oversample admitted patients, which they assumed impacted education more than non-admitted patients.
The median score was 16 of 20. ED crowding levels were NOT associated with ER scores or their individual domains.
How fascinating that learners still felt that the quality of teaching and learning in the ED was maintained despite the ED being overwhelmed beyond capacity.
The next step is to follow Kirkpatrick’s model in conducting educational research. In this model, satisfaction/reaction-based studies are the first (lowest) tier. Such studies inherently have flaws based on bias, recall, and halo effect. The next study is to look at more objective measures assessing the impact of crowding on education. Hmm, I better get going on my manuscript.
Pines JM, Prabhu A, McCusker CM, Hollander JE. The effect of ED crowding on education. Amer J Emerg Med (2010) 28, 217–220.
This is is a great look back at how SAEM Tests were developed and now used by EM clerkships across the country. Because EM does not have a National Board of Medical Examiners shelf exam, a tremendous effort was made by the authors to create a set of validated questions for clerkship directors to use.
Specifically point serial correlation coefficients (range -1 to +1) were calculated for each question. A high coefficient means a high correlation between the performance on the individual test question and the performance on the overall test. After rewriting 25% of the test questions because of poor correlation coefficients, all current test questions now have a point serial correlation coefficient >0.2. (more…)
Thanks to EB Medicine, “Emergency Medicine Practice” articles from 2007 and earlier are now free! This series is a well-written and practical evidence-based review resource for EM physicians. It’s a great place to start reading about bread-and-butter EM content, especially for medical students and junior residents. There haven’t been too much change in the past 3 years on many of the topics.