Volume 16, Issue 6, November 2015.
Emily L. Aaronson, MD, et al.

Introduction: Morbidity and mortality conferences (M+M) are a traditional part of residency training
and mandated by the Accreditation Counsel of Graduate Medical Education. This study’s objective
was to determine the goals, structure, and the prevalence of practices that foster strong safety
cultures in the M+Ms of U.S. emergency medicine (EM) residency programs.
Methods: The authors conducted a national survey of U.S. EM residency program directors. The
survey instrument evaluated five domains of M+M (Organization and Infrastructure; Case Finding;
Case Selection; Presentation; and Follow up) based on the validated Agency for Healthcare
Research & Quality Safety Culture survey.
Results: There was an 80% (151/188) response rate. The primary objectives of M+M were
discussing adverse outcomes (53/151, 35%), identifying systems errors (47/151, 31%) and
identifying cognitive errors (26/151, 17%). Fifty-six percent (84/151) of institutions have anonymous
case submission, with 10% (15/151) maintaining complete anonymity during the presentation and
21% (31/151) maintaining partial anonymity. Forty-seven percent (71/151) of programs report a
formal process to follow up on systems issues identified at M+M. Forty-four percent (67/151) of
programs report regular debriefing with residents who have had their cases presented.
Conclusion: The structure and goals of M+Ms in EM residencies vary widely. Many programs lack
features of M+M that promote a non-punitive response to error, such as anonymity. Other programs
lack features that support strong safety cultures, such as following up on systems issues or reporting
back to residents on improvements. Further research is warranted to determine if M+M structure is
related to patient safety culture in residency programs.

Volume 16, Issue 6, November 2015.
Suzanne Bentley, MD, MPH, et al.

Introduction: The focused assessment with sonography for trauma (FAST) is a commonly used and
life-saving tool in the initial assessment of trauma patients. The recommended emergency medicine
(EM) curriculum includes ultrasound and studies show the additional utility of ultrasound training for
medical students. EM clerkships vary and often do not contain formal ultrasound instruction. Time
constraints for facilitating lectures and hands-on learning of ultrasound are challenging. Limitations
on didactics call for development and inclusion of novel educational strategies, such as simulation.
The objective of this study was to compare the test, survey, and performance of ultrasound between
medical students trained on an ultrasound simulator versus those trained via traditional, hands-on
patient format.
Methods: This was a prospective, blinded, controlled educational study focused on EM clerkship
medical students. After all received a standardized lecture with pictorial demonstration of image
acquisition, students were randomized into two groups: control group receiving traditional training
method via practice on a human model and intervention group training via practice on an ultrasound
simulator. Participants were tested and surveyed on indications and interpretation of FAST and training
and confidence with image interpretation and acquisition before and after this educational activity.
Evaluation of FAST skills was performed on a human model to emulate patient care and practical skills
were scored via objective structured clinical examination (OSCE) with critical action checklist.
Results: There was no significant difference between control group (N=54) and intervention group
(N=39) on pretest scores, prior ultrasound training/education, or ultrasound comfort level in general
or on FAST. All students (N=93) showed significant improvement from pre- to post-test scores and
significant improvement in comfort level using ultrasound in general and on FAST (p<0.001). There
was no significant difference between groups on OSCE scores of FAST on a live model. Overall, no
differences were demonstrated between groups trained on human models versus simulator.
Discussion: There was no difference between groups in knowledge based ultrasound test scores,
survey of comfort levels with ultrasound, and students’ abilities to perform and interpret FAST on
human models.
Conclusion: These findings suggest that an ultrasound simulator is a suitable alternative method
for ultrasound education. Additional uses of ultrasound simulation should be explored in the future.

Volume 16, Issue 6, November 2015.
Aaron W. Bernard, MD, et al.

Introduction: Press Ganey (PG) scores are used by public entities to gauge the quality of patient
care from medical facilities in the United States. Academic health centers (AHCs) are charged
with educating the new generation of doctors, but rely heavily on PG scores for their business
operation. AHCs need to know what impact medical student involvement has on patient care and
their PG scores.
Purpose: We sought to identify the impact students have on emergency department (ED) PG scores
related to overall visit and the treating physician’s performance.
Methods: This was a retrospective, observational cohort study of discharged ED patients who
completed PG satisfaction surveys at one academic, and one community-based ED. Outcomes
were responses to questions about the overall visit assessment and doctor’s care, measured on a
five-point scale. We compared the distribution of responses for each question through proportions
with 95% confidence intervals (CIs) stratified by medical student participation. For each question, we
constructed a multivariable ordinal logistic regression model including medical student involvement
and other independent variables known to affect PG scores.
Results: We analyzed 2,753 encounters, of which 259 (9.4%) had medical student involvement. For
all questions, there were no appreciable differences in patient responses when stratifying by medical
student involvement. In regression models, medical student involvement was not associated with
PG score for any outcome, including overall rating of care (odds ratio [OR] 1.10, 95% CI [0.90-1.34])
or likelihood of recommending our EDs (OR 1.07, 95% CI [0.86-1.32]). Findings were similar when
each ED was analyzed individually.
Conclusion: We found that medical student involvement in patient care did not adversely impact
ED PG scores in discharged patients. Neither overall scores nor physician-specific scores were
impacted. Results were similar at both the academic medical center and the community teaching
hospital at our institution.

Volume 16, Issue 6, November 2015.
Keme Carter, MD, et al.

Introduction: An important area of communication in healthcare is the consultation. Existing literature
suggests that formal training in consultation communication is lacking. We aimed to conduct a targeted
needs assessment of third-year students on their experience calling consultations, and based on these
results, develop, pilot, and evaluate the effectiveness of a consultation curriculum for different learner
levels that can be implemented as a longitudinal curriculum.
Methods: Baseline needs assessment data were gathered using a survey completed by third-year
students at the conclusion of the clinical clerkships. The survey assessed students’ knowledge of
the standardized consultation, experience and comfort calling consultations, and previous instruction
received on consultation communication. Implementation of the consultation curriculum began the
following academic year. Second-year students were introduced to Kessler’s 5 Cs consultation
model through a didactic session consisting of a lecture, viewing of “trigger” videos illustrating
standardized and informal consults, followed by reflection and discussion. Curriculum effectiveness
was assessed through pre- and post- curriculum surveys that assessed knowledge of and comfort
with the consultation process. Fourth-year students participated in a consultation curriculum that
provided instruction on the 5 Cs model and allowed for continued practice of consultation skills through
simulation during the Emergency Medicine clerkship. Proficiency in consult communication in this
cohort was assessed using two assessment tools, the Global Rating Scale and the 5 Cs Checklist.
Results: The targeted needs assessment of third-year students indicated that 93% of students
have called a consultation during their clerkships, but only 24% received feedback. Post-curriculum,
second-year students identified more components of the 5 Cs model (4.04 vs. 4.81, p<0.001) and
reported greater comfort with the consultation process (0% vs. 69%, p<0.001). Post- curriculum,
fourth-year students scored higher in all criteria measuring consultation effectiveness (p<0.001 for
all) and included more necessary items in simulated consultations (62% vs. 77%, p<0.001).
Conclusion: While third-year medical students reported calling consultations, few felt comfortable
and formal training was lacking. A curriculum in consult communication for different levels of learners
can improve knowledge and comfort prior to clinical clerkships and improve consultation skills prior
to residency training.

Volume 16, Issue 6, November 2015.
Kim L. Askew, MD, et al.

Introduction: To determine if there is any correlation between any of the 10 individual components
of a global rating index on an emergency medicine (EM) student clerkship evaluation form. If there
is correlation, to determine if a weighted average of highly correlated components loses predictive
value for the final clerkship grade.
Methods: This study reviewed medical student evaluations collected over two years of a required
fourth-year rotation in EM. Evaluation cards, comprised of a detailed 10-part evaluation, were
completed after each shift. We used a correlation matrix between evaluation category average
scores, using Spearman’s rho, to determine if there was any correlation of the grades between any
of the 10 items on the evaluation form.
Results: A total of 233 students completed the rotation over the two-year period of the study. There
were strong correlations (>0.80) between assessment components of medical knowledge, history
taking, physical exam, and differential diagnosis. There were also strong correlations between
assessment components of team rapport, patient rapport, and motivation. When these highly
correlated were combined to produce a four-component model, linear regression demonstrated
similar predictive power in terms of final clerkship grade (R2
=0.71, CI95=0.65–0.77 and R2
=0.69,
CI95=0.63–0.76 for the full and reduced models respectively).
Conclusion: This study revealed that several components of the evaluation card had a high degree
of correlation. Combining the correlated items, a reduced model containing four items (clinical skills,
interpersonal skills, procedural skills, and documentation) was as predictive of the student’s clinical
grade as the full 10-item evaluation. Clerkship directors should be aware of the performance of their
individual global rating scales when assessing medical student performance, especially if attempting
to measure greater than four components.

Volume 16, Issue 6, November 2015.
Aimee M. Rolston, MD, MS, et al.

Introduction: Choosing a residency program is a stressful and important decision. Doximity
released residency program rankings by specialty in September 2014. This study sought to
investigate the impact of those rankings on residency application choices made by fourth year
medical students.
Methods: A 12-item survey was administered in October 2014 to fourth year medical students
at three schools. Students indicated their specialty, awareness of and perceived accuracy of the
rankings, and the rankings’ impact on the programs to which they chose to apply. Descriptive
statistics were reported for all students and those applying to Emergency Medicine (EM).
Results: A total of 461 (75.8%) students responded, with 425 applying in one of the 20 Doximity
ranked specialties. Of the 425, 247 (58%) were aware of the rankings and 177 looked at them. On
a 1-100 scale (100=very accurate), students reported a mean ranking accuracy rating of 56.7 (SD
20.3). Forty-five percent of students who looked at the rankings modified the number of programs to
which they applied. The majority added programs. Of the 47 students applying to EM, 18 looked at
the rankings and 33% changed their application list with most adding programs.
Conclusion: The Doximity rankings had real effects on students applying to residencies as almost
half of students who looked at the rankings modified their program list. Additionally, students found
the rankings to be moderately accurate. Graduating students might benefit from emphasis on more
objective characterization of programs to assess in light of their own interests and personal/career
goals.

Volume 16, Issue 6, November 2015.
Diane L. Gorgas, MD, et al.

Introduction: Emotional Intelligence (EI) is defined as an ability to perceive another’s emotional
state combined with an ability to modify one’s own. Physicians with this ability are at a distinct
advantage, both in fostering teams and in making sound decisions. Studies have shown that
higher physician EI’s are associated with lower incidence of burn-out, longer careers, more positive
patient-physician interactions, increased empathy, and improved communication skills. We explored
the potential for EI to be learned as a skill (as opposed to being an innate ability) through a brief
educational intervention with emergency medicine (EM) residents.
Methods: This study was conducted at a large urban EM residency program. Residents were
randomized to either EI intervention or control groups. The intervention was a two-hour session
focused on improving the skill of social perspective taking (SPT), a skill related to social awareness.
Due to time limitations, we used a 10-item sample of the Hay 360 Emotional Competence Inventory
to measure EI at three time points for the training group: before (pre) and after (post) training, and at
six-months post training (follow up); and at two time points for the control group: pre- and follow up.
The preliminary analysis was a four-way analysis of variance with one repeated measure: Group x
Gender x Program Year over Time. We also completed post-hoc tests.
Results: Thirty-three EM residents participated in the study (33 of 36, 92%), 19 in the EI intervention
group and 14 in the control group. We found a significant interaction effect between Group and
Time (p<0.05). Post-hoc tests revealed a significant increase in EI scores from Time 1 to 3 for the EI
intervention group (62.6% to 74.2%), but no statistical change was observed for the controls (66.8%
to 66.1%, p=0.77). We observed no main effects involving gender or level of training.
Conclusion: Our brief EI training showed a delayed but statistically significant positive impact on
EM residents six months after the intervention involving SPT. One possible explanation for this
finding is that residents required time to process and apply the EI skills training in order for us to
detect measurable change. More rigorous measurement will be needed in future studies to aid in the
interpretation of our findings.