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This survey study examines the frequency, types, and sources of perceived workplace mistreatment and the prevalence of suicidal ideation among emergency medicine residents in the US., Key Points Question What is the prevalence of workplace mistreatment and suicidal thoughts among emergency medicine residents? Findings In this survey study of 7680 emergency medicine residents, 45.1% reported exposure to some type of workplace mistreatment (eg, discrimination, abuse, or harassment) and 2.5% reported having suicidal thoughts during the most recent academic year. The prevalence of workplace mistreatment and suicidal thoughts was similar by gender and race/ethnicity. Meaning The findings suggest that educational interventions are warranted to reduce workplace mistreatment and ensure emergency medicine residents’ well-being during training., Importance The prevalence of workplace mistreatment and its association with the well-being of emergency medicine (EM) residents is unclear. More information about the sources of mistreatment might encourage residency leadership to develop and implement more effective strategies to improve professional well-being not only during residency but also throughout the physician’s career. Objective To examine the prevalence, types, and sources of perceived workplace mistreatment during training among EM residents in the US and the association between mistreatment and suicidal ideation. Design, Setting, and Participants In this survey study conducted from February 25 to 29, 2020, all residents enrolled in EM residencies accredited by the Accreditation Council for Graduate Medical Education (ACGME) who participated in the 2020 American Board of Emergency Medicine computer-based In-training Examination were invited to participate. A multiple-choice, 35-item survey was administered after the examination asking residents to self-report the frequency, sources, and types of mistreatment experienced during residency training and whether they had suicidal thoughts. Main Outcomes and Measures The types and frequency of workplace mistreatment and the sources of the mistreatment were identified, and rates of self-reported suicidality were obtained. Multivariable logistic regression models were used to examine resident and program characteristics associated with suicidal thoughts. Results Of 8162 eligible EM residents, 7680 (94.1%) responded to at least 1 question on the survey; 6503 (79.7%) completed the survey in its entirety. A total of 243 ACGME-accredited residency programs participated, and 1 did not. The study cohort included 4768 male residents (62.1%), 2698 female residents (35.1%), 4919 non-Hispanic White residents (64.0%), 2620 residents from other racial/ethnic groups (Alaska Native, American Indian, Asian or Pacific Islander, African American, Mexican American, Native Hawaiian, Puerto Rican, other Hispanic, or mixed or other race) (34.1%), 483 residents who identified as lesbian, gay, bisexual, transgender, queer, or other (LGBTQ+) (6.3%), and 5951 residents who were married or in a relationship (77.5%). Of the total participants, 3463 (45.1%) reported exposure to some type of workplace mistreatment (eg, discrimination, abuse, or harassment) during the most recent academic year. A frequent source of mistreatment was identified as patients and/or patients’ families; 1234 respondents (58.7%) reported gender discrimination, 867 (67.5%) racial discrimination, 282 (85.2%) physical abuse, and 723 (69.1%) sexual harassment from patients and/or family members. Suicidal thoughts occurring during the past year were reported by 178 residents (2.5%), with similar prevalence by gender (108 men [2.4%]; 59 women [2.4%]) and race/ethnicity (113 non-Hispanic White residents [2.4%]; 65 residents from other racial/ethnic groups [2.7%]). Conclusions and Relevance In this survey study, EM residents reported that workplace mistreatment occurred frequently. The findings suggest common sources of mistreatment for which educational interventions may be developed to help ensure resident wellness and career satisfaction.

Health care inequity is corrected more readily when safe, high-quality care is provided by physicians who reflect the gender, race, and ethnicity of patient communities. It is important to train and evaluate racially diverse physicians involved in residency training.This study sought to determine any test-taking differences for black Emergency Medicine (EM) residents and whether any such differences would narrow as residency progressed.This was an observational, cross-sectional study that reviewed performance (scaled scores) on the American Board of Emergency Medicine (ABEM) In-Training Examination (ITE) for 2018, 2019, and 2020. The study included EM residents in 3-year programs who took the ITE. A linear regression model was used for the variables of race, which included black physicians and white physicians (reference group), and level of training (EM resident year 1 [EM1] as the reference group).There were 9591 residents included; 539 were black and 9052 were white. Mean scaled scores were higher as a function of training level. Regression showed a scaled score intercept of 73.51. The ITE score increased for all groups as a function of training level (EM2 β = +5.45, p0.0001; EM3 β = +8.09, p0.0001). The regression coefficient for black residents was -5.87 (p0.0001). There was relative improvement by training level compared with improvement in the reference group, but this difference was not materially or statistically significant.In this study of the ABEM ITE, a test-taking performance gap identified early in residency for black physicians persisted into late residency.

INTRODUCTION: Beginning in 1999, residents in emergency medicine have been expected to demonstrate competence in the six Accreditation Council on Graduate Medical Education (ACGME) Core Competencies. Expectations were further refined and clarified through the introduction of the Milestones in 2013. Emerging research and data from milestone reporting has illustrated the need for modification of the original milestones. Against this backdrop, the ACGME convened a committee to review and revise the original milestones. METHODS: The working group was convened in December 2018 and consisted of representatives from the American Board of Emergency Medicine, American Osteopathic Association, Council of Residency Directors in Emergency Medicine, Association of American Medical Colleges, ACGME‐Emergency Medicine Review Committee, three community members, a resident member, and a public member. This group also included members from both academic and community emergency medicine programs. The group was overseen by the ACGME vice president for milestones development and met in person one time followed by four virtual sessions to revise and draft the Emergency Medicine Milestones and Supplemental Guide as part of the ACGME Milestones 2.0 Project. RESULTS: Using data from milestones reporting, needs assessment data, stakeholder interviews, and community commentary, the working group engaged in revisions and updates for the Emergency Medicine Milestones and created a supplemental guide to aid programs in the design of programmatic assessment for the milestones. CONCLUSION: The Emergency Medicine Milestones 2.0 provide updated specialty‐specific, competency‐based behavioral anchors to guide the assessment of residents, the design of curricula, and the advancement of emergency medicine training programs.

Background Graduates of emergency medicine residency programs can seek certification from the American Board of Emergency Medicine (ABEM), yet the costs and perceived value by residents is not clear. Objective This report sought to better define the value of board certification by asking physicians taking the ABEM Oral Certification Examination (OCE) to describe its costs (eg, time, money) and perceived benefits. Methods A descriptive, cross-sectional, voluntary, anonymous survey was administered to physicians taking the 2018 spring and fall ABEM OCEs. Response frequencies were used to report response rates. Results There were 2016 physicians who participated in the 2018 OCEs, of whom 1565 (78%) completed a survey. With respect to preparation, 38% (599 of 1565 responses) spent more than 30 hours preparing for the examination. Regarding the expense of preparing for the examination, 21% (328) spent nothing, 50% (776) spent less than $1,000, and 2% (38) spent more than $3,000. Most physicians (80%, 1254) reported a learning benefit to preparing for and taking the OCE. There were 49% (765) of respondents who reported that preparing for the examination reinforced their knowledge of emergency medicine; 20% (311) reported no learning benefit. Most physicians (92%, 1442) reported that ABEM certification provided a career benefit, the most common of which was more career opportunities (69%, 1076). Conclusions Initial certification requires a considerable investment of time and money. Physicians seeking initial ABEM certification found both learning and professional benefits, with the most frequently reported being reinforcement of medical knowledge and more career opportunities.

Supplemental Digital Content is available in the text., Purpose To investigate whether clinical competency committees (CCCs) were consistent in applying milestone ratings for first-year residents over time or whether ratings increased or decreased. Method Beginning in December 2013, the Accreditation Council for Graduate Medical Education (ACGME) initiated a phased-in requirement for reporting milestones; emergency medicine (EM), diagnostic radiology (DR), and urology (UR) were among the earliest reporting specialties. The authors analyzed CCC milestone ratings of first-year residents from 2013 to 2016 from all ACGME-accredited EM, DR, and UR programs for which they had data. The number of first-year residents in these programs ranged from 2,838 to 2,928 over this time period. The program-level average milestone rating for each subcompetency was regressed onto the time of observation using a random coefficient multilevel regression model. Results National average program-level milestone ratings of first-year residents decreased significantly over the observed time period for 32 of the 56 subcompetencies examined. None of the other subcompetencies showed a significant change. National average in-training examination scores for each of the specialties remained essentially unchanged over the time period, suggesting that differences between the cohorts were not likely an explanatory factor. Conclusions The findings indicate that CCCs tend to become more stringent or maintain consistency in their ratings of beginning residents over time. One explanation for these results is that CCCs may become increasingly comfortable in assigning lower ratings when appropriate. This finding is consistent with an increase in confidence with the milestone rating process and the quality of feedback it provides.

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine-sponsored residency and fellowship programs, residents and fellows training in those programs, and all fellows for whom ABEM issues subspecialty certifications. We present the 2019 annual report on the status of US emergency medicine training programs.

The American Board of Emergency Medicine gathers extensive background information on the Accreditation Council of Graduate Medical Education-accredited emergency medicine residency and fellowship programs, as well as the residents and fellows training in those programs. We present the 2022 annual report on the status of physicians training in Accreditation Council of Graduate Medical Education-accredited emergency medicine training programs in the United States.

Objectives Burnout afflicts emergency physicians (EPs) to a significant degree. The impact of burnout spans from decreased clinical efficiency to increased medical errors to heightened risk of physician suicide. This large‐scale study captures responses from emergency medicine (EM) residents regarding two burnout items and examines the correlation between in‐training examination (ITE) scores and burnout risk as well as that between residency year and burnout risk. Methods This was a prospective, mixed‐methods, cross‐sectional cohort study. All residents in U.S. categorical EM residents who took the 2019 ITE were included. At the end of the ITE, residents were invited to complete a voluntary survey that included two items from the Maslach Burnout Inventory (MBI) that have been found to be strongly indicative of burnout: one about self‐perception of being burned out and one about feelings of callousness. Responses were on a 7‐level Likert scale (1–7), ranging from very low frequency (1) to very high frequency (7). Measurements included the number of residents in each year‐level of training (EM1–EM4), the MBI item ratings, and the ABEM ITE score. Performance, as measured by the scaled, equated score, was compared to the MBI item responses. A corrected Spearman’s correlation coefficient (ρ) was used to compare continuous data (score) against a discrete ordinal variable (MBI Likert response). Results There were 2,501 EM1 residents, 2,389 EM2 residents, 2,206 EM3 residents, and 616 EM4 residents in the study group. There were 7,206 (93.4%) physicians who completed the first MBI question about burnout; 7,172 (93%) completed the second MBI question about callousness. There was no statistically significant association between the burnout item response and ITE performance (ρ = –0.03; p = 0.015). There was a positive, statistically significant association between the callousness item response and higher ITE performance (ρ = 0.07; p < 0.001). There was a statistically significant association between the response to the burnout item and training level (ρ = 0.07; p

The American Board of Emergency Medicine gathers extensive background information on Accreditation Council for Graduate Medical Education (ACGME)–accredited emergency medicine residency and fellowship programs, as well as the residents and fellows training in those programs. We present the 2020 annual report on the status of physicians training in ACGME-accredited emergency medicine training programs in the United States.

BACKGROUND: The field of clinical informatics (CI), and specifically the electronic health record, has been identified as a key facilitator to achieve a sustainable evidence‐based health care system for the future. International graduate medical education (GME) programs have been challenged to ensure that their trainees are provided with appropriate skills to deliver effective and efficient health care in an evolving environment. OBJECTIVES: This study explored how international emergency medicine (EM) specialist training standards address competencies and training in relevant areas of CI. METHODS: A list of categories of CI competencies relative to EM was developed following a thematic review of published references documenting CI curriculum and competencies. Publicly available documents outlining core content, curriculum, and competencies from international organizations responsible for specialty GME and/or credentialing in EM for Australasia, Canada, Europe, the United Kingdom, and the United States were identified. These EM training standards were reviewed to identify inclusion of topics related to the relevant categories of CI competencies. RESULTS: A total of 23 EM curriculum documents were included in the review. Curricula content related to critical appraisal/evidence‐based medicine, leadership, quality improvement, and privacy/security were included in all EM curricula. The CI topics related to fundamental computer skills, computerized provider order entry, and patient‐centered informatics were only included in the EM curricula documents for the United States and were absent for the other jurisdictions. CONCLUSION: There is variation in the CI‐related content of the international EM specialty training standards reviewed. Given the increasing importance of CI in the future delivery of health care, organizations responsible for training and credentialing specialist emergency physicians must ensure that their training standards incorporate relevant CI content, thus ensuring that their trainees gain competence in essential aspects of CI.

Background In 2013, milestone ratings became a reporting requirement for emergency medicine (EM) residency programs. Programs rate each resident in the fall and spring on 23 milestone subcompetencies. Objective This study examined the incidence of straight line scoring (SLS) for EM Milestone ratings, defined as a resident being assessed the same score across the milestone subcompetencies. Methods This descriptive analysis measured the frequencies of SLS for all Accreditation Council for Graduate Medical Education (ACGME)–accredited EM programs during the 2015–2016 academic year. Outcomes were the frequency of SLS in the fall and spring milestone assessments, changes in the number of SLS reports, and reporting trends. Chi-square analysis compared nominal variables. Results There were 6257 residents in the fall and 6588 in the spring. Milestone scores were reported for 6173 EM residents in the fall (99% of 6257) and spring (94% of 6588). In the fall, 93% (5753 residents) did not receive SLS ratings and 420 (7%) did, with no significant difference compared with the spring (5776 [94%] versus 397 [6%]). Subgroup analysis showed higher SLS results for residents' first ratings (183 of 2136 versus 237 of 4220, P < .0001) and for their final ratings (200 of 2019 versus 197 of 4354, P < .0001). Twenty percent of programs submitted 10% or more SLS ratings, and a small percentage submitted more than 50% of ratings as SLS. Conclusions Most programs did not submit SLS ratings. Because of the statistical improbability of SLS, any SLS ratings reduce the validity assertions of the milestone assessments.

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency programs and the residents training in those programs. We present the 2017 annual report on the status of US emergency medicine training programs.

Author(s): Miller, Emily S.; Heitz, Corey; Ross, Linette P.; Beeson, Michael S. | Abstract: n/a

Author(s): Hart, Danielle; Franzen, Douglas; Beeson, Michael; Bhat, Rahul; Kulkarni, Miriam; Thibodeau, Lorraine; Weizberg, Moshe; Promes, Susan | Abstract: Introduction: Medical education is moving toward a competency-based framework with a focus on assessment using the Accreditation Council for Graduate Medical Education Milestones. Assessment of individual competencies through milestones can be challenging. While competencies describe characteristics of the person, the entrustable professional activities (EPAs) concept refers to work-related activities. EPAs would not replace the milestones but would be linked to them, integrating these frameworks. Many core specialties have already defined EPAs for resident trainees, but EPAs have not yet been created for emergency medicine (EM). This paper describes the development of milestone-linked EPAs for EM. Methods: Ten EM educators from across North America formed a consensus working group to draft EM EPAs, using a modified Glaser state-of-the-art approach. A reactor panel with EPA experts from the United States, Canada and the Netherlands was created, and an iterative process with multiple revisions was performed based on reactor panel input. Following this, the EPAs were sent to the Council of Residency Directors for EM (CORD-EM) listserv for additional feedback.Results: The product was 11 core EPAs that every trainee from every EM program should be able to perform independently by the time of graduation. Each EPA has associated knowledge, skills, attitudes and behaviors (KSAB), which are either milestones themselves or KSABs linked to individual milestones. We recognize that individual programs may have additional focus areas or work-based activities they want their trainees to achieve by graduation; therefore, programs are also encouraged to create additional program-specific EPAs. Conclusion: This set of 11 core, EM-resident EPAs can be used as an assessment tool by EM residency programs, allowing supervising physicians to document the multiple entrustment decisions they are already making during clinical shifts with trainees. The KSAB list within each EPA could assist supervisors in giving specific, actionable feedback to trainees and allow trainees to use this list as an assessment-for-learning tool. Linking each KSAB to individual EM milestones allows EPAs to directly inform milestone assessment for clinical competency committees. These EPAs serve as another option for workplace-based assessment, and are linked to the milestones to create an integrated framework.

Background Version 1 (V1) of the National Emergency Medicine Fourth-year Student (EM M4) Examination was released in 2011 and revised along with release of V2 in 2012. Each examination contains 50 multiple-choice questions designed to assess knowledge in the EM M4 clerkship curriculum. Development and initial performance data were described previously. Objective To provide updated V1 performance data, describe development and revision of V2, and to compare performance between academic years and examination forms, and within academic years. Methods Examinations are administered at www.saemtests.org with ongoing performance data provided. After 1 year of use, nine questions on V2 were revised, five because of low discriminatory ability and four because of excessive difficulty. Revision or replacement was done in accordance with the National Board of Medical Examiners (NBME) Item Writing Guidelines. Mean scores were compared for V1 between academic years (i.e., July 2011−June 2012 vs. July 2012−June 2013), V2 compared with V1, and for each examination version for early and late test takers. Results V1 has been administered >10,000 times since its release, and the current form mean is 81.5% (SD 3.7). Average discriminatory value (rpb) is 0.204. V2 has been administered >1500 times, with a mean score of 78.4% (SD 4.4) and average rpb 0.253. V1 and V2 current means differ statistically. Scores from examinees completing V1 or V2 early vs. late in the academic year differ statistically. Conclusions Performance data for V1 remain stable after 2 years. Revisions of poorly performing questions improved question performance on V2. Questions with low rpb or low pdiff will continue to be revised annually. While examination forms differ statistically, the practical utility of the differences is not defined.

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine–sponsored residency and fellowship programs, as well as the residents and fellows training in those programs. We present the 2018 annual report on the status of US emergency medicine training programs.

Introduction: Since 2011 two online, validated exams for fourth-year emergency medicine (EM) students have been available (National EM M4 Exams). In 2013 the National Board of Medical Examiners offered the Advanced Clinical Examination in Emergency Medicine (EM-ACE). All of these exams are now in widespread use; however, there are no data on how they correlate. This study evaluated the correlation between the EM-ACE exam and the National EM M4 Exams. Methods: From May 2013 to April 2014 the EM-ACE and one version of the EM M4 exam were administered sequentially to fourth-year EM students at five U.S. medical schools. Data collected included institution, gross and scaled scores and version of the EM M4 exam. We performed Pearson’s correlation and random effects linear regression. Results: 303 students took the EM-ACE and versions 1 (V1) or 2 (V2) of the EM M4 exams (279 and 24, respectively). The mean percent correct for the exams were as follows: EM-ACE 74.8 (SD-8.83), V1 83.0 (SD-6.41), V2 78.5 (SD-7.70). Pearson’s correlation coefficient for the V1/EM-ACE was 0.51 (0.42 scaled) and for the V2/EM-ACE was 0.59 (0.41 scaled). The coefficient of determination for V1/EM-ACE was 0.72 and for V2/EM-ACE = 0.71 (0.86 and 0.49 for scaled scores). The R-squared values were 0.25 and 0.30 (0.18 and 0.13, scaled), respectively. There was significant cluster effect by institution. Conclusion: There was moderate positive correlation of student scores on the EM-ACE exam and the National EM M4 Exams. [West J Emerg Med. 2015;16(1):–0.]

In this issue an article, Goal Directed Focused Ultrasound Milestones Revised: A Multi-organizational Consensus, recommends significant change to the PC 12 subcompetency of the Emergency Medicine (EM) Milestones. The membership of this consensus group spans multiple organizations and individuals interested in emergency ultrasound (EUS) as well as resident education. This effort to improve this particular subcompetency is to be lauded. An iterative improvement to the progression of Milestones within PC12 can be justified on the basis of a large body of work produced after the introduction of the EM Milestones. However, there are a number of misperceptions within the article that deserve discussion. As a member of the original Emergency Medicine Milestone Working Group (EMMWG) I can address these suggested changes. This article is protected by copyright. All rights reserved.

The American Board of Emergency Medicine gathers extensive background information on emergency medicine residency programs and the residents in them. We present the 2014 annual report on the status of US emergency medicine training programs.

Objectives The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties sought to define milestones for skill and knowledge acquisition during residency training. Milestones are significant objective observable events. The milestones are listed within a structure that is derived from the ACGME general competencies. Major groups of milestones are called “subcompetencies.” The original 24 subcompetencies containing 255 milestones for emergency medicine (EM) were developed through a multiorganizational group representing most EM stakeholder groups. To assure that the milestones reflected EM resident progress throughout training, the EM Milestones Working Group (EM MWG) sought to validate the individual milestones. Methods A computer-based survey was sent to all EM residency programs. The survey period began on April 30, 2012, and concluded on May 15, 2012. Respondents were asked to assign each milestone to a specific level of skill or knowledge acquisition. These levels ranged from a beginning resident to an accomplished clinician. There were two different forms that divided the milestones into two groups of 12 subcompetencies each. Surveys were randomly assigned to programs. Results There were five respondents (the program director and four key faculty) requested from each of the 159 residences. There were responses from 96 programs (60.4%). Of the 795 survey recipients, 28 were excluded due to prior exposure to the EM milestones. Of the remaining 767 potential respondents, 281 completed the survey (36.6%) within a 16-day period. Based on the survey results, the working group adjusted the milestones in the following ways: one entire subcompetency (teaching) was eliminated, six new milestones were created, 34 milestones were eliminated, 26 milestones were reassigned to a lower level score, and 20 were reassigned to a higher level. Nineteen milestones were edited to provide greater clarity. The final result was 227 discrete milestones among 23 subcompetencies. Conclusions The EM milestones were validated through a milestone assignment process using a computer-based survey completed by program directors and key faculty. Milestones were revised in accordance with the results to better align assignment within each performance level. Resumen Los Objetivos por Areas de la Medicina de Urgencias y Emergencias: Un Estudio de Validacion Objetivos El Accreditation Council for Graduate Medical Education (ACGME) y la American Board of Medical Specialties buscaron definir los objetivos por areas para la adquisicion de las habilidades y el conocimiento durante la formacion de la residencia. Los objetivos por areas son hechos observables objetivos y significativos. Los objetivos por areas se enumeran en una estructura que se deriva de las competencias generales del ACGME. Los grupos mayores de los objetivos por areas se denominan subcompetencias. Las 24 subcompetencias originales que contienen 255 objetivos por areas para la medicina de urgencias y emergencias (MUE) se desarrollaron a traves de un grupo de varias organizaciones que representan a la mayoria de los grupos interesados en la MUE. Para asegurar que los objetivos por areas reflejaron el progreso del residente de MUE mediante la formacion, el grupo de trabajo de los objetivos por areas de la MUE busco validar individualmente estos objetivos. Metodologia Se envio una encuesta electronica a todos los programas de residencia de MUE. El periodo de la encuesta comenzo el 30 de abril de 2012 y concluyo el 15 de mayo de 2012. Se solicito a los respondedores que asignaran a cada uno de los objetivos por areas un nivel especifico de adquisicion de habilidades o conocimiento. Estos niveles variaron desde el residente a su inicio hasta un clinico consumado. Hubo dos formularios diferentes que dividieron los objetivos por areas en dos grupos de 12 subcompetencias cada uno. Las encuestas se asignaron de forma aleatoria a los programas. Resultados Se seleccionaron cinco respondedores (el director de programa y cuatro profesores representativos de la facultad) para cada una de los 159 programas de residencia. Hubo respuestas de 96 programas (60,4%). De las 795 encuestas recibidas, 28 se excluyeron debido a la experiencia previa en los objetivos por areas de la MUE. De los restantes, 767 respondedores potenciales, 281 completaron la encuesta (36,6%) en un periodo de 16 dias. En base a los resultados de la encuesta, el grupo de trabajo ajusto los objetivos por areas de la siguiente manera: se elimino una subcompetencia integra (ensenanza), se crearon 6 nuevos objetivos por areas, se eliminaron 34 objetivos por areas, se reasignaron 26 objetivos por areas a un nivel menor y 20 a un nivel mayor. Se corrigieron 19 objetivos por areas para proporcionar una mayor claridad. El resultado final fueron 227 objetivos por areas distintos en 23 subcompetencias. Conclusiones Los objetivos por areas de la MUE se validaron a traves de un proceso de asignacion de objetivos por areas mediante una encuesta electronica completada por los directores de los programas y profesores representativos de la facultad. Los objetivos por areas se revisaron de acuerdo a los resultados para una mejor alineacion de las asignaciones en cada nivel de realizacion.

Background The Model of the Clinical Practice of Emergency Medicine is the basis for the content specifications of all American Board of Emergency Medicine (ABEM) examinations. This study describes the frequency with which ABEM diplomates diagnose and manage the conditions and components listed in the Model of the Clinical Practice of Emergency Medicine. Objectives The objectives of this study were to determine the frequency with which ABEM diplomates diagnose and manage the conditions and components described in the Model of the Clinical Practice of Emergency Medicine. Methods The listing of conditions and components of the Model of the Clinical Practice of Emergency Medicine were sent to 16,230 randomly selected ABEM diplomates. One of five surveys was sent to each diplomate. Each condition and component was assessed by participants for the frequency that emergency physicians diagnose (D) and manage (M) that condition, as seen in their practice of Emergency Medicine. Results Of the 16,230 surveys sent, 5006 were returned (30.8% response rate). The genders of the respondents were 75% male and 24% female. The ages of the respondents were primarily in the age 40–49 years, and 30–39 years age groups. All categories of the listing of conditions and components of the Model of the Clinical Practice of Emergency Medicine were encountered frequently in the practice of Emergency Medicine, as indicated by study participants. Conclusions A survey of practicing ABEM diplomates was useful in defining the frequency with which specific conditions and components are diagnosed and managed in the practice of Emergency Medicine.

Michael S. Beeson, MD, MBA, is Residency Program Director in the Department of Emergency Medicine, Akron General Medical Center; Wallace A. Carter, MD, is Residency Program Director in the Department of Emergency Medicine, New York Presbyterian Hospital; Theodore A. Christopher, MD, is Professor and Chairman of the Department of Emergency Medicine, Thomas Jefferson University and Hospitals; Jonathan W. Heidt, MD, is Clinical Instructor in the Division of Emergency Medicine, Washington University School of Medicine in St Louis; James H. Jones, MD, is Professor of Clinical Emergency Medicine in the Department of Emergency Medicine, Indiana University School of Medicine; Lynne E. Meyer, PhD, MPH, is Executive Director of the Review Committee for Emergency Medicine, Accreditation Council for Graduate Medical Education; Susan B. Promes, MD, is Professor and Vice Chair for Education in the Department of Emergency Medicine, University of California, San Francisco; Kevin G. Rodgers, MD, is Professor in the Department of Emergency Medicine, Indiana University School of Medicine; Philip H. Shayne, MD, is Professor and is Program Director and Vice Chair for Education in the Department of Emergency Medicine, Emory University School of Medicine; Mary Jo Wagner, MD, is Residency Program Director and Chief in the Department of Emergency Medicine, Central Michigan University College of Medicine; and Susan R. Swing, PhD, is Vice President of Outcome Assessment at the Accreditation Council for Graduate Medical Education.

The Model of the Clinical Practice of Emergency Medicine (the EM Model) is a three-dimensional representation of the clinical practice of emergency medicine. It is a product of successful collaboration involving the American Board of Emergency Medicine (ABEM), the American College of Emergency Physicians (ACEP), the Society for Academic Emergency Medicine (SAEM), the Emergency Medicine Residents' Association (EMRA), the Council of Emergency Medicine Residency Directors (CORD), the Residency Review Committee for Emergency Medicine (RRC-EM), and the American Academy of Emergency Medicine (AAEM). In 2017, the most recent update and revision of the EM Model will be published. This document will represent the culmination of nearly 40 years of evolution, from a simple listing of presenting patient complaints, clinical symptoms, and disease states into a three-dimensional representation of the clinical practice of emergency medicine. These dimensions include conditions and components, physician tasks, and patient acuity. In addition, over the years, two other documents have been developed, the Knowledge, Skills, and Abilities (KSAs) and the Emergency Medicine Milestones. Both serve as related and complementary educational and assessment tools. This article will review the development of the EM Model from its inception in 1979 to today.

Introduction: End-of-shift evaluation (ESE) forms, also known as daily encounter cards, represent a subset of encounter-based assessment forms. Encounter cards have become prevalent for formative evaluation, with some suggesting a potential for summative evaluation. Our objective was to evaluate the inter-rater agreement of ESE forms using a single scripted encounter at a conference of emergency medicine (EM) educators. Methods: Following institutional review board exemption, we created a scripted video simulating an encounter between an intern and a patient with an ankle injury. That video was shown during a lecture at the Council of EM Residency Director’s Academic Assembly with attendees asked to evaluate the “resident” using one of eight possible ESE forms randomly distributed. Descriptive statistics were used to analyze the results with Fleiss’ kappa to evaluate inter-rater agreement. Results: Most of the 324 respondents were leadership in residency programs (66%), with a range of 29-47 responses per evaluation form. Few individuals (5%) felt they were experts in assessing residents based on EM milestones. Fleiss’ kappa ranged from 0.157 - 0.308 and did not perform much better in two post-hoc subgroup analyses. Conclusion: The kappa ranges found show only slight to fair inter-rater agreement and raise concerns about the use of ESE forms in assessment of EM residents. Despite limitations present in this study, these results and a lack of other studies on inter-rater agreement of encounter cards should prompt further studies of such methods of assessment. Additionally, EM educators should focus research on methods to improve inter-rater agreement of ESE forms or other evaluating other methods of assessment of EM residents. [West J Emerg Med. 2017;18(3)518-524.]

The American Board of Emergency Medicine (ABEM) gathers extensive background information on emergency medicine residency programs and the residents training in those programs. We present the 2016 annual report on the status of US emergency medicine training programs.

This project was developed from the research network track at the 2012 Academic Emergency Medicine consensus conference on education research in emergency medicine (EM). Using a combination of consensus techniques, the modified Delphi method, and qualitative research methods, the authors describe multiple aspects of developing, implementing, managing, and growing an EM education research network. A total of 175 conference attendees and 24 small-group participants contributed to discussions regarding an education research network; participants were experts in research networks, education, and education research. This article summarizes relevant conference discussions and expert opinion for recommendations on the structure of an education research network, basic operational framework, site selection, leadership, subcommittees, guidelines for authorship, logistics, and measuring success while growing and maintaining the network.

Written examinations are frequently used to assess medical student performance. Within emergency medicine (EM), a National Board of Medical Examiners (NBME) subject examination for EM clerkships does not exist. As a result, clerkship directors frequently generate examinations within their institution. This article reviews the literature behind the use of standardized examinations in evaluating medical student performance, describes methods for generating well-written test questions, reviews the statistical concepts of reliability and validity that are necessary to evaluate an examination, and proposes future directions for testing EM students.

Background Representatives of emergency medicine (EM) were asked to develop a consensus report that provided a review of the past and potential future effects of duty hour requirements for EM residency training. In addition to the restrictions made in 2003 by the Accreditation Council for Graduate Medical Education, the potential effects of the 2008 Institute of Medicine (IOM) report on resident duty hours were postulated. Discussion The elements highlighted include patient safety, resident wellness, and the resident training experience. Many of the changes and recommendations did not affect EM as significantly as other specialties. Current training standards in EM have already emphasized patient safety by requiring continuous onsite supervision of residents. Resident fatigue has been addressed with restrictions of shift lengths and limitation of consecutive days worked. Conclusion One recommendation from the IOM was a required 5-h rest period for residents on call. Emergency department (ED) patient safety becomes an important concern with the decrease in the availability and in the patient load of a resident consultant that may result from this recommendation. Of greater concern is the already observed slower throughput time for admitted patients waiting for resident care, which will increase ED crowding and decrease patient safety in academic institutions. A balance between being overly prescriptive with duty hour restrictions and trying to improve resident wellness was recommended. Discussion is included regarding the appropriate length of EM training programs if clinical experiences were limited by new duty hour regulations. Finally, this report presents a review of the financing issues associated with any changes.

Introduction: The field of Clinical Informatics (CI) and specifically the electronic health record, has been identified as a key facilitator to achieve a sustainable evidence-based healthcare system for the future. International graduate medical education programs have been challenged to ensure their trainees are provided with appropriate skills to deliver effective and efficient healthcare in an evolving environment. This study explored how international Emergency Medicine (EM) specialist training standards address training in relevant areas of CI. Methods: A list of categories of CI competencies relative to EM was developed following a thematic review of published references documenting CI curriculum and competencies. Publically available, published documents outlining core content, curriculum and competencies from international organizations responsible for specialty graduate medical education and/or credentialing in EM for the United States, Canada, Australasia, the United Kingdom and Europe. These EM training standards were reviewed to identify inclusion of topics related to the relevant categories of CI competencies. Results: A total of 23 EM curriculum documents were included in the thematic analysis. Curricula content related to critical appraisal/evidence based medicine, leadership, quality improvement and privacy/security were included in all EM curricula. The CI topics related to fundamental computer skills, computerized provider order entry and patient-centered informatics were only included in the EM curricula documents for the United States and were absent for each other organization. Conclusion: There is variation in the CI related content of the international EM specialty training standards which were reviewed. Given the increasing importance of CI in the future delivery of healthcare, organizations responsible for training and credentialing specialist emergency physicians must ensure their training standards incorporate relevant CI content, thus ensuring their trainees gain competence in essential aspects of CI.

Objectives: To examine the effectiveness of an asynchronous learning tool consisting of web-based lectures for trainees covering major topics pertinent to pediatric emergency medicine (PEM) and to assess resident and student evaluation of this mode of education. Methods: PEM faculty and fellows created a 21-lecture, web-based curriculum. These 20-minute online lectures used Microsoft PowerPoint with the voice-over feature. A 75-question test was created to assess the effectiveness of the web-based learning model, administered online before and after the rotation in the pediatric emergency department (PED). All fourth-year medical students and residents (across all specialties) rotating through the PED were required to complete 10 of the 21 lectures during their 1-month rotation. The main outcome variable was difference in score between pre- and post-rotation tests of participants who viewed no lectures and those who viewed at least one lecture. Evaluation of the program was assessed by anonymous survey using 5-point discrete visual analog scales. Responses of 4 or 5 were considered positive for analysis. Results: One hundred eleven residents and fourth-year medical students participated in the program. An initial 32 completed testing before implementation of the on-line lectures (March 2007–August 2007), and another five did not complete the on-line lectures after implementation (September 2007–February 2008). Seventy-one completed testing and on-line lectures, and all but three completed at least 10 on-line lectures during their rotation. Fourteen of 111 trainees did not complete the pre- or post-test (including two who viewed the lectures). The mean change in score was a 1% improvement from pre-test to post-test for trainees who viewed no lectures and a 6.2% improvement for those who viewed the lectures (mean difference = 5.2%, 95% confidence interval = 2.5% to 7.9%). In the linear regression model, the estimate of the coefficient was 0.43 (p < 0.001), meaning that, for each lecture viewed, post-test score rose by 0.43%. Sixty-nine of 75 test items (92%) had a point biserial correlation greater than 0.15. Thirty of the 72 trainees who completed the online lectures and testing (42%) returned surveys. All were comfortable using the Internet, and 87% (26/30) found the web-site easy to use. All felt that their educational goals were met, and 100% felt that the format would be useful in other areas of education. Conclusions: Although not a replacement for traditional bedside teaching, the use of web-based lectures as an asynchronous learning tool has a positive effect on medical knowledge test scores. Trainees were able to view online lectures on their own schedules, in the location of their choice. This is helpful in a field with shift work, in which trainees rarely work together, making it difficult to synchronously provide lectures to all trainees.

Nationwide survey findings that most U.S. emergency medicine clerkship directors were interested in participating in a methodologically rigorous student testing program prompted the development of the Society for Academic Emergency Medicine (SAEM) Medical Student Online Testing Service (SAEM Tests). This article describes the development of SAEM Tests and details usage and progress since the on-line release in June 2005. Specifically, we review the construction of SAEM Tests and present validity and difficulty statistics obtained at the first analysis of test performance 6 months after its release and again 12 months later after revisions aimed at enhancing test performance. We then review the current status of SAEM Tests and summarize future goals and directions.

Objective: A panel of Council of Emergency Medicine Residency Directors (CORD) members was asked to examine and make recommendations regarding the existing Accreditation Council of Graduate Medical Education (ACGME) EM Program Requirements pertaining to educational conferences, identified best practices, and recommended revisions as appropriate. Methods: Using quasi-Delphi technique, 30 emergency medicine (EM) residency program directors and faculty examined existing requirements. Findings were presented to the CORD members attending the 2008 CORD Academic Assembly, and disseminated to the broader membership through the CORD e-mail list server. Results: The following four ACGME EM Program Requirements were examined, and recommendations made: 1 The 5 hours/week conference requirement: For fully accredited programs in good standing, outcomes should be driving how programs allocate and mandate educational time. Maintain the 5 hours/week conference requirement for new programs, programs with provisional accreditation, programs in difficult political environs, and those with short accreditation cycles. If the program requirements must retain a minimum hours/week reference, future requirements should take into account varying program lengths (3 versus 4 years). 2 The 70% attendance requirement: Develop a new requirement that allows programs more flexibility to customize according to local resources, individual residency needs, and individual resident needs. 3 The requirement for synchronous versus asynchronous learning: Synchronous and asynchronous learning activities have advantages and disadvantages. The ideal curriculum capitalizes on the strengths of each through a deliberate mixture of each. 4 Educationally justified innovations: Transition from process-based program requirements to outcomes-based requirements. Conclusions: The conference requirements that were logical and helpful years ago may not be logical or helpful now. Technologies available to educators have changed, the amount of material to cover has grown, and online on-demand education has grown even more. We believe that flexibility is needed to customize EM education to suit individual resident and individual program needs, to capitalize on regional and national resources when local resources are limited, to innovate, and to analyze and evaluate interventions with an eye toward outcomes.

There is a large push to utilize evidence-based practices in medical education. At the same time, credentialing bodies are evaluating the use of simulation technologies to assess the competency and safety of its practitioners. At the 2008 Academic Emergency Medicine Consensus Conference on "The Science of Simulation in Healthcare," our breakout session critically evaluated several issues important to the use of simulation in emergency physician (EP) assessment. In this article, we discuss five topics felt to be most critical to simulation-based assessment (SBA). We then offer more specific research questions that would help to define and implement a SBA program in emergency medicine (EM).

Legionella pneumophila infection is a recognized but rare cause of rhabdomyolysis. While the mechanism of rhabdomyolysis associated with Legionella is unknown, theories include direct invasion of Legionella into the muscle itself, or the release of its endotoxin into the circulation with subsequent muscle injury. In this case report, we describe a case of Legionella pneumonia presenting as altered mental status, high fever, and rhabdomyolysis with acute renal failure. We review the epidemiology, clinical and laboratory findings, and treatment of the disease.

Objectives: To characterize emergency medicine (EM) program directors (PDs) and compare the data, where possible, with those from other related published studies. Methods: An online survey was e-mailed in 2002 to all EM PDs of programs that were approved by the Accreditation Council of Graduate Medical Education. The survey included questions concerning demographics, work hours, support staff, potential problems and solutions, salary and expenses, and satisfaction. Results: One hundred nine of 124 (88%) PDs (69.7% university, 27.5% community, and 2.8% military) completed the survey; 85.3% were male. Mean age was 43.6 years (95% confidence interval [CI] = 42.6 to 44.7 yr). The mean time as a PD was 5.7 years (95% CI = 4.9 to 6.5 yr), with 56% serving five years or less. The mean time expected to remain as PD is an additional 6.0 years (95% CI = 5.2 to 6.8). A 1995 study noted that 50% of EM PDs had been in the position for less than three years, and 68% anticipated continuing in their position for less than five years. On a scale of 1 to 10 (with 10 as highest), the mean satisfaction with the position of PD was 8.0 (95% CI = 7.2 to 8.3). Those PDs who stated that the previous PD had mentored them planned to stay a mean of 2.0 years longer than did those who were not mentored (95% CI of difference of means = 0.53 to 3.53). Sixty-five percent of PDs had served previously as an associate PD. Most PDs (92%) have an associate or assistant PD, with 54% reporting one; 25%, two; and 9%, three associate or assistant PDs. A 1995 study noted that 62% had an associate PD. Ninety-two percent have a program coordinator, and 35% stated that they have both a residency secretary and a program coordinator. Program directors worked a median of 195 hours per month: clinical, 75 hours; scholarly activity, 20 hours; administrative, 80 hours; and teaching and residency conferences, 20 hours; compared with a median total hours of 220 previously reported. Lack of adequate time to do the job required, career needs interfering with family needs, and lack of adequate faculty help with residency matters were identified as the most important problems (means of 3.5 [95% CI = 3.2 to 3.7], 3.4 [95% CI = 3.2 to 3.6], and 3.1 [95% CI = 2.9 to 3.3], respectively, on a scale of 1 to 5, with 5 as maximum). This study identified multiple resources that were found to be useful by >50% of PDs, including national meetings, lectures, advice from others, and self-study. Conclusions: Emergency medicine PDs generally are very satisfied with the position of PD, perhaps because of increased support and resources. Although PD turnover remains an issue, PDs intend to remain in the position for a longer period of time than noted before this study. This may reflect the overall satisfaction with the position as well as the increased resources and support now available to the PD. PDs have greater satisfaction if they have been mentored for the position.

Temporomandibular joint (TMJ) dislocation is an infrequent dislocation of the mandible. The usual technique of reduction, recommended by most Emergency Medicine textbooks, consists of downward forces applied to the mandible. In the authors' experience this is often painful and requires significant sedation. We present a patient in whom the usual manner of TMJ dislocation reduction was difficult. We describe a novel technique for TMJ dislocation reduction that uses the intrinsic biomechanical properties of the mandible.

Objectives The Accreditation Council for Graduate Medical Education (ACGME) Milestones describe behavioral markers for the progressive acquisition of competencies during residency. As a key component of the Next Accreditation System, all residents are evaluated for the acquisition of specialty-specific Milestones. The objective was to determine the validity and reliability of the emergency medicine (EM) Milestones. Methods The ACGME and the American Board of Emergency Medicine performed this single-event observational study. The data included the initial EM Milestones performance ratings of all categorical EM residents submitted to the ACGME from October 31, 2013, to January 6, 2014. Mean performance ratings were determined for all 23 subcompetencies for every year of residency training. The internal consistency (reliability) of the Milestones was determined using a standardized Cronbach's alpha coefficient. Exploratory factor analysis was conducted to determine how the subcompetencies were interrelated. Results EM Milestone performance ratings were obtained on 100% of EM residents (n = 5,805) from 162 residency programs. The mean performance ratings of the aggregate and individual subcompetency scores showed discrimination between residency years, and the factor structure further supported the validity of the EM Milestones. The reliability was α = 0.96 within each year of training. Conclusions The EM Milestones demonstrated validity and reliability as an assessment instrument for competency acquisition. EM residents can be assured that this evaluation process has demonstrated validity and reliability; faculty can be confident that the Milestones are psychometrically sound; and stakeholders can know that the Milestones are a nationally standardized, objective measure of specialty-specific competency acquisition.

In the Original Research article entitled “Correlation of the National Board of Medical Examiners Advanced Clinical Examination in Emergency Medicine and the National Emergency Medicine M4 Exams,” published in the January 2015 issue of the Western Journal of Emergency Medicine (2015;16(1):138–142. DOI: 10.5811/westjem.2014.11.24189), there were the following errors in the published article: On page 138, the 1st line of the results section of the abstract should read: 305 students took the EM-ACE and versions 1 (V1) or 2 (V2) of the EM M4 exams (281 and 24, respectively). On page 138, the 2nd line of the results section of the abstract should read: The mean percent correct for the exams were as follows: EM-ACE 74.9 (SD-9.82), V1 83.0 (SD-6.39), V2 78.5 (SD-7.70). On page 138, the 3rd line of the results section of the abstract should read: Pearson’s correlation coefficient for the V1/EM-ACE was 0.53 (0.43 scaled) and for the V2/EM-ACE was 0.58 (0.41 scaled). On page 138, the 4th line of the results section of the abstract should read: The coefficient of determination for V1/EM-ACE was 0.73 and for V2/EM-ACE 0.71 (0.65 and .49 for scaled scores) [ERRATUM]. The R-squared values were 0.28 and 0.30 (0.18 and 0.13 scaled), respectively. On page 140, the 1st line of the results section should read: Five institutions administered both the NBME EM-ACE and one version of the EM M4 exam to 305 fourth-year students at the end of their EM rotation. V1 of the EM M4 was administered to 281 students, and V2 to 24 students. On page 140, the fifth sentence of the results section should read: The mean NBME scaled score for the entire cohort was 68.3 (SD-9.66). On page 141 in the table, the Pearson’s Correlation coefficient for “NBME (raw) V1 EM M4” should be 0.53 and “NBME (scaled) V1 EM M4” 0.43. On page 141 in the table, the R-squared value for “NBME (raw) V1 EM M4” should be 0.28. The correct Figures for “Figure 1” and Figure 2” on page 140 are shown on the following page: Figure 1 Correlation of NBME EM-ACE and National EM M4 V1 and V2. Figure 2 Correlation of NBME EM-ACE and National EM M4 V1 and V2. We apologize for this error.