With the risk of violence being so high in the emergency department (ED), it is essential for ED physicians and staff to have an understanding of the progression of violence and the appropriate de-escalation techniques to defuse potentially violent situations. Techniques for de-escalation should occur in a step-wise pattern beginning with verbal techniques, followed by the offering of a pharmacologic intervention, a show of force, and finally physical restraint. At times, it may be necessary to use physical restraints until parenteral medications have had their desired effect. The most frequently used medication strategies consist of benzodiazepines, second-generation antipsychotic medications alone or in combination with a benzodiazepine, and haloperidol (Haldol) alone or in combination with a benzodiazepine. The ED can best be prepared for a hostage crisis by developing well-defined procedures for securing the area, for alerting the appropriate law enforcement agencies, and by designating clear lines of authority.
All residency programs in the United States are required to report their residents' progress on the milestones to the Accreditation Council for Graduate Medical Education (ACGME) biannually. Since the development and institution of this competency-based assessment framework, residency programs have been attempting to ascertain the best ways to assess resident performance on these metrics. Simulation was recommended by the ACGME as one method of assessment for many of the milestone subcompetencies. We developed three simulation scenarios with scenario-specific milestone-based assessment tools. We aimed to gather validity evidence for this tool.We conducted a prospective observational study to investigate the validity evidence for three mannequin-based simulation scenarios for assessing individual residents on emergency medicine (EM) milestones. The subcompetencies (i.e., patient care [PC]1, PC2, PC3) included were identified via a modified Delphi technique using a group of experienced EM simulationists. The scenario-specific checklist (CL) items were designed based on the individual milestone items within each EM subcompetency chosen for assessment and reviewed by experienced EM simulationists. Two independent live raters who were EM faculty at the respective study sites scored each scenario following brief rater training. The inter-rater reliability (IRR) of the assessment tool was determined by measuring intraclass correlation coefficient (ICC) for the sum of the CL items as well as the global rating scales (GRSs) for each scenario. Comparing GRS and CL scores between various postgraduate year (PGY) levels was performed with analysis of variance.Eight subcompetencies were chosen to assess with three simulation cases, using 118 subjects. Evidence of test content, internal structure, response process, and relations with other variables were found. The ICCs for the sum of the CL items and the GRSs were >0.8 for all cases, with one exception (clinical management GRS = 0.74 in sepsis case). The sum of CL items and GRSs (p < 0.05) discriminated between PGY levels on all cases. However, when the specific CL items were mapped back to milestones in various proficiency levels, the milestones in the higher proficiency levels (level 3 [L3] and 4 [L4]) did not often discriminate between various PGY levels. L3 milestone items discriminated between PGY levels on five of 12 occasions they were assessed, and L4 items discriminated only two of 12 times they were assessed.Three simulation cases with scenario-specific assessment tools allowed evaluation of EM residents on proficiency L1 to L4 within eight of the EM milestone subcompetencies. Evidence of test content, internal structure, response process, and relations with other variables were found. Good to excellent IRR and the ability to discriminate between various PGY levels was found for both the sum of CL items and the GRSs. However, there was a lack of a positive relationship between advancing PGY level and the completion of higher-level milestone items (L3 and L4).
The teaching of calculus in secondary schools in British Columbia, apart from International Baccalaureate (IB) and Advanced Placement (AP) Calculus, has taken many forms throughout the years. Calculus started as a locally developed course, then changed to an introductory chapter in Mathematics 12, and now is a Ministry-approved course with a provincial curriculum. These changes came at a time when universities in the United States were reexamining the calculus courses being offered in their institutions. This review in the mid 1980's started a movement now known as calculus reform. The major themes of the reform movement were in alignment with the common themes in mathematics education: changing pedagogy to a student-centred approach, making students accountable for understanding mathematics and not relying on rote memorization, giving mathematics a context student can relate to, and incorporating technology into the learning of mathematics. This investigation was designed to analyze how the calculus reform movement has influenced the teaching of calculus in secondary schools in British Columbia. The analysis included the Calculus 12 curriculum, the textbooks commonly used by secondary school teachers, the university challenge examinations, and professional development opportunities. To form a basis for this comparison an analysis was also carried out on one of the first calculus textbook designed using a reform model (the Harvard Book). Evidence was found that the British Columbia Calculus 12 curriculum shared many common themes, as found in the literature review and the Harvard book, with calculus reform. It appears that calculus reform has influenced the intended calculus course. However the intended calculus course is often different than that implemented in classrooms. The responses by teachers to a survey on teaching practices revealed that many of the calculus reform themes are present in secondary schools. No definitive statement can be made to suggest that calculus reform is the main reason for this. However, with smaller classrooms, availability of technology and teachers using current educational practices, secondary schools may be an ideal setting to what reformers had in mind when they envisioned a calculus reform course. ltiir worf+ dedkated to my entire famib: M y mom anddadwho made me the man that I am, M y loving wlfe who gives me the strength to 6e the man that I am, a n d m y three wondetfulchiliiren who inspire me to 6e the man I shoulii6e.
Introduction: Interviewing for residency is a complicated and often expensive endeavor. Literature has estimated interview costs of $4,000 to $15,000 per applicant, mostly attributable to travel and lodging. The authors sought to reduce these costs and improve the applicant interview experience by coordinating interview dates between two residency programs in .Methods: Two emergency medicine residency programs scheduled contiguous interview dates for the 2015-2016 interview season. A survey was used to assess applicant experiences interviewing in and attitudes regarding coordinated scheduling. Data on utilization of coordinated dates were obtained from interview scheduling software. The target group for this intervention consisted of applicants from medical schools outside that completed interviews at both programs.Results: Of the 158 applicants invited to both programs, 84 (53%) responded to the survey. Scheduling data was available for all applicants. The total estimated cost savings for target applicants coordinating interview dates was $18,600. The majority of target applicants reported that this intervention increased the ease of scheduling (84%), made them less likely to cancel the interview (82%) and saved them money (71%).Conclusions: Coordinated scheduling of interview dates was associated with significant estimated cost savings and was reviewed favorably by applicants across all measures of experience. Expanding use of this practice geographically and across specialties may further reduce the cost of interviewing for applicants.
Importance Adaptive expertise helps physicians apply their skills to novel clinical cases and reduce preventable errors. Error management training (EMT) has been shown to improve adaptive expertise with procedural skills; however, its application to cognitive skills in medical education is unclear. Objective To evaluate whether EMT improves adaptive expertise when learning the cognitive skill of head computed tomography (CT) interpretation. Design, Setting, and Participants This 3-arm randomized clinical trial was conducted from July 8, 2022, to March 30, 2023, in 7 geographically diverse emergency medicine residency programs. Participants were postgraduate year 1 through 4 emergency medicine residents masked to the hypothesis. Interventions Participants were randomized 1:1:1 to a difficult EMT, easy EMT, or error avoidance training (EAT) control learning strategy for completing an online head CT curriculum. Both EMT cohorts received no didactic instruction before scrolling through head CT cases, whereas the EAT group did. The difficult EMT cohort answered difficult questions about the teaching cases, leading to errors, whereas the easy EMT cohort answered easy questions, leading to fewer errors. All 3 cohorts used the same cases. Main Outcomes and Measures The primary outcome was a difference in adaptive expertise among the 3 cohorts, as measured using a head CT posttest. Secondary outcomes were (1) differences in routine expertise, (2) whether the quantity of errors during training mediated differences in adaptive expertise, and (3) the interaction between prior residency training and the learning strategies. Results Among 212 randomized participants (mean [SD] age, 28.8 [2.0] years; 107 men [50.5%]), 70 were allocated to the difficult EMT, 71 to the easy EMT, and 71 to the EAT control cohorts; 150 participants (70.8%) completed the posttest. The difficult EMT cohort outperformed both the easy EMT and EAT cohorts on adaptive expertise cases (60.6% [95% CI, 56.1%-65.1%] vs 45.2% [95% CI, 39.9%-50.6%], vs 40.9% [95% CI, 36.0%-45.7%], respectively; P &lt; .001), with a large effect size (η 2 = 0.19). There was no significant difference in routine expertise. The difficult EMT cohort made more errors during training than the easy EMT cohort. Mediation analysis showed that the number of errors during training explained 87.2% of the difficult EMT learning strategy’s effect on improving adaptive expertise ( P = .01). The difficult EMT learning strategy was more effective in improving adaptive expertise for residents earlier in training, with a large effect size (η 2 = 0.25; P = .002). Conclusions and Relevance In this randomized clinical trial, the findings show that EMT is an effective method to develop physicians’ adaptive expertise with cognitive skills. Trial Registration ClinicalTrials.gov Identifier: NCT05284838
Abstract Objectives Medical education fellowships in emergency medicine (EM) provide training in teaching, assessment, educational program administration, and scholarship. The longitudinal impact of this training is unknown. Our objective was to characterize the career outcomes of medical education fellowship graduates. Methods We solicited curriculum vitae (CV) from graduates of U.S. EM education fellowships by email. We abstracted data from CVs with a standard instrument that included program characteristics, employment history, leadership positions, awards, and scholarly productivity. We calculated and reported descriptive statistics. Results A total of 71 of 91 (78%) graduates participated. Thirty‐three completed a 1‐year fellowship and 38 completed a 2‐year fellowship. Nineteen (27%) completed an advanced degree during fellowship. Median (range) graduation year was 2016 (1997–2020). The majority, 63 of 71 (89%), work in an academic setting. Graduates held leadership positions in continuing medical education, graduate medical education, and undergraduate medical education. Forty‐eight (68%) served on national medical education committees. The mean ± SD number of national medical education awards was 1.27 ± 2.03. The mean ± SD number of national medical education presentations was 7.63 ± 10.83. Graduates authored a mean ± SD of 3.63 ± 5.81 book chapters and a mean ± SD of 4.99 ± 6.17 peer‐reviewed medical education research publications. Ten (14%) served on journal editorial boards, 34 (48%) were journal reviewers, and 31 (44%) had received a medical education grant. Conclusion EM medical education fellowship graduates are academically productive and hold education leadership positions.
