Volume 16, Issue 6, November 2015.
Moira Flanigan, BA, et al.

Introduction: The Accreditation Council for Graduate Medical Education requires that residency
programs ensure resident competency in performing safe, effective handoffs. Understanding
resident, attending, and nurse perceptions of the key elements of a safe and effective emergency
department (ED) handoff is a crucial step to developing feasible, acceptable educational
interventions to teach and assess this fundamental competency. The aim of our study was to identify
the essential themes of ED-based handoffs and to explore the key cultural and interprofessional
themes that may be barriers to developing and implementing successful ED-based educational
handoff interventions.
Methods: Using a grounded theory approach and constructivist/interpretivist research paradigm, we
analyzed data from three primary and one confirmatory focus groups (FGs) at an urban, academic
ED. FG protocols were developed using open-ended questions that sought to understand what
participants felt were the crucial elements of ED handoffs. ED residents, attendings, a physician
assistant, and nurses participated in the FGs. FGs were observed, hand-transcribed, audiorecorded
and subsequently transcribed. We analyzed data using an iterative process of theme and
subtheme identification. Saturation was reached during the third FG, and the fourth confirmatory
group reinforced the identified themes. Two team members analyzed the transcripts separately and
identified the same major themes.
Results: ED providers identified that crucial elements of ED handoff include the following: 1) Culture
(provider buy-in, openness to change, shared expectations of sign-out goals); 2) Time (brevity,
interruptions, waiting); 3) Environment (physical location, ED factors); 4) Process (standardization,
information order, tools).
Conclusion: Key participants in the ED handoff process perceive that the crucial elements of
intershift handoffs involve the themes of culture, time, environment, and process. Attention to these
themes may improve the feasibility and acceptance of educational interventions that aim to teach
and assess handoff competency.

Volume 16, Issue 6, November 2015.
Mark Silverberg, MD

Introduction: The primary objective of this study was to determine the prevalence of remediation,
competency domains for remediation, the length, and success rates of remediation in emergency
medicine (EM).
Methods: We developed the survey in SurveymonkeyTM with attention to content and response
process validity. EM program directors responded how many residents had been placed on
remediation in the last three years. Details regarding the remediation were collected including
indication, length and success. We reported descriptive data and estimated a multinomial logistic
regression model.
Results: We obtained 126/158 responses (79.7%). Ninety percent of programs had at least one
resident on remediation in the last three years. The prevalence of remediation was 4.4%. Indications
for remediation ranged from difficulties with one core competency to all six competencies (mean
1.9). The most common were medical knowledge (MK) (63.1% of residents), patient care (46.6%)
and professionalism (31.5%). Mean length of remediation was eight months (range 1-36 months).
Successful remediation was 59.9% of remediated residents; 31.3% reported ongoing remediation. In
8.7%, remediation was deemed “unsuccessful.” Training year at time of identification for remediation
(post-graduate year [PGY] 1), longer time spent in remediation, and concerns with practice-based
learning (PBLI) and professionalism were found to have statistically significant association with
unsuccessful remediation.
Conclusion: Remediation in EM residencies is common, with the most common areas being MK
and patient care. The majority of residents are successfully remediated. PGY level, length of time
spent in remediation, and the remediation of the competencies of PBLI and professionalism were
associated with unsuccessful remediation.

Volume 16, Issue 6, November 2015.
Corey Heitz, MD, et al.

Introduction: Linking educational objectives and clinical learning during clerkships can be difficult.
Clinical shifts during emergency medicine (EM) clerkships provide a wide variety of experiences,
some of which may not be relevant to recommended educational objectives. Students can be
directed to standardize their clinical experiences, and this improves performance on examinations.
We hypothesized that applying a “flipped classroom” model to the clinical clerkship would improve
performance on multiple-choice testing when compared to standard learning.
Methods: Students at two institutions were randomized to complete two of four selected EM
clerkship topics in a “flipped fashion,” and two others in a standard fashion. For flipped topics,
students were directed to complete chief complaint-based asynchronous modules prior to a shift,
during which they were directed to focus on the chief complaint. For the other two topics, modules
were to be performed at the students’ discretion, and shifts would not have a theme. At the end
of the four-week clerkship, a 40-question multiple-choice examination was administered with 10
questions per topic. We compared performance on flipped topics with those performed in standard
fashion. Students were surveyed on perceived effectiveness, ability to follow the protocol, and
willingness of preceptors to allow a chief-complaint focus.
Results: Sixty-nine students participated; examination scores for 56 were available for analysis. For
the primary outcome, no difference was seen between the flipped method and standard (p=0.494.)
A mixed model approach showed no effect of flipped status, protocol adherence, or site of rotation
on the primary outcome of exam scores. Students rated the concept of the flipped clerkship highly
(3.48/5). Almost one third (31.1%) of students stated that they were unable to adhere to the protocol.
Conclusion: Preparation for a clinical shift with pre-assigned, web-based learning modules followed
by an attempt at chief-complaint-focused learning during a shift did not result in improvements in
performance on a multiple-choice assessment of knowledge; however, one third of participants did
not adhere strictly to the protocol. Future investigations should ensure performance of pre-assigned
learning as well as clinical experiences, and consider alternate measures of knowledge.

Volume 16, Issue 6, November 2015.
Fiona E. Gallahue, MD, et al.

This study aimed to assess current education and practices of emergency medicine (EM) residents
as perceived by EM program directors to determine if there are deficits in resident discharge handoff
training. This survey study was guided by the Kern model for medical curriculum development.
A six-member Council of EM Residency Directors (CORD) Transitions of Care task force of EM
physicians performed these steps and constructed a survey. The survey was distributed to program
residency directors via the CORD listserve and/or direct contact. There were 119 responses to the
survey, which were collected using an online survey tool. Over 71% of the 167 American College of
Graduate Medical Education (ACGME) accredited EM residency programs were represented. Of
those responding, 42.9% of programs reported formal training regarding discharges during initial
orientation and 5.9% reported structured curriculum outside of orientation. A majority (73.9%) of
programs reported that EM residents were not routinely evaluated on their discharge proficiency.
Despite the ACGME requirements requiring formal handoff curriculum and evaluation, many
programs do not provide formal curriculum on the discharge transition of care or evaluate EM
residents on their discharge proficiency.

Volume 16, Issue 6, November 2015.
Christopher Kiefer, MD, et al.

Introduction: Performance on patient satisfaction surveys is becoming increasingly important for
practicing emergency physicians and the introduction of learners into a new clinical environment
may impact such scores. This study aimed to quantify the impact of introducing fourth-year medical
students on patient satisfaction in two university-affiliated community emergency departments (EDs).
Methods: Two community-based EDs in the Indiana University Health (IUH) system began
hosting medical students in March 2011 and October 2013, respectively. We analyzed responses
from patient satisfaction surveys at each site for seven months before and after the introduction
of students. Two components of the survey, “Would you recommend this ED to your friends
and family?” and “How would you rate this facility overall?” were selected for analysis, as they
represent the primary questions reviewed by the Center for Medicare Services (CMS) as part of
value-based purchasing. We evaluated the percentage of positive responses for adult, pediatric,
and all patients combined.
Results: Analysis did not reveal a statistically significant difference in the percentage of positive
response for the “would you recommend” question at both clinical sites with regards to the adult
and pediatric subgroups, as well as the all-patient group. At one of the sites, there was significant
improvement in the percentage of positive response to the “overall rating” question following the
introduction of medical students when all patients were analyzed (60.3% to 68.2%, p=0.038).
However, there was no statistically significant difference in the “overall rating” when the pediatric or
adult subgroups were analyzed at this site and no significant difference was observed in any group
at the second site.
Conclusion: The introduction of medical students in two community-based EDs is not associated
with a statistically significant difference in overall patient satisfaction, but was associated with a
significant positive effect on the overall rating of the ED at one of the two clinical sites studied.
Further study is needed to evaluate the effect of medical student learners upon patient satisfaction in
settings outside of a single health system.

Volume 16, Issue 6, November 2015.
Suzanne L. Strom, MD, et al.

Introduction: Traditional Advanced Cardiac Life Support (ACLS) courses are evaluated using written
multiple-choice tests. High-fidelity simulation is a widely used adjunct to didactic content, and has been
used in many specialties as a training resource as well as an evaluative tool. There are no data to our
knowledge that compare simulation examination scores with written test scores for ACLS courses.
Objective: To compare and correlate a novel high-fidelity simulation-based evaluation with
traditional written testing for senior medical students in an ACLS course.
Methods: We performed a prospective cohort study to determine the correlation between simulation based
evaluation and traditional written testing in a medical school simulation center. Students
were tested on a standard acute coronary syndrome/ventricular fibrillation cardiac arrest scenario.
Our primary outcome measure was correlation of exam results for 19 volunteer fourth-year medical
students after a 32-hour ACLS-based Resuscitation Boot Camp course. Our secondary outcome
was comparison of simulation-based vs. written outcome scores.
Results: The composite average score on the written evaluation was substantially higher (93.6%)
than the simulation performance score (81.3%, absolute difference 12.3%, 95% CI [10.6-14.0%],
p<0.00005). We found a statistically significant moderate correlation between simulation scenario
test performance and traditional written testing (Pearson r=0.48, p=0.04), validating the new
evaluation method.
Conclusion: Simulation-based ACLS evaluation methods correlate with traditional written testing
and demonstrate resuscitation knowledge and skills. Simulation may be a more discriminating and
challenging testing method, as students scored higher on written evaluation methods compared to
simulation.

Volume 16, Issue 6, November 2015.
Grant Wei, MD, et al.

Introduction: The effect of emergency department (ED) crowding has been recognized as a
concern for more than 20 years; its effect on productivity, medical errors, and patient satisfaction
has been studied extensively. Little research has reviewed the effect of ED crowding on medical
education. Prior studies that have considered this effect have shown no correlation between ED
crowding and resident perception of quality of medical education.
Objective: To determine whether ED crowding, as measured by the National ED Overcrowding
Scale (NEDOCS) score, has a quantifiable effect on medical student objective and subjective
experiences during emergency medicine (EM) clerkship rotations.
Methods: We collected end-of-rotation examinations and medical student evaluations for 21 EM
rotation blocks between July 2010 and May 2012, with a total of 211 students. NEDOCS scores were
calculated for each corresponding period. Weighted regression analyses examined the correlation
between components of the medical student evaluation, student test scores, and the NEDOCS score
for each period.
Results: When all 21 rotations are included in the analysis, NEDOCS scores showed a negative
correlation with medical student tests scores (regression coefficient= -0.16, p=0.04) and three
elements of the rotation evaluation (attending teaching, communication, and systems-based
practice; p<0.05). We excluded an outlying NEDOCS score from the analysis and obtained similar
results. When the data were controlled for effect of month of the year, only student test score
remained significantly correlated with NEDOCS score (p=0.011). No part of the medical student
rotation evaluation attained significant correlation with the NEDOCS score (p≥0.34 in all cases).
Conclusion: ED overcrowding does demonstrate a small but negative association with medical
student performance on end-of-rotation examinations. Additional studies are recommended to further
evaluate this effect.

Volume 16 , Issue 6, November 2015.
Katherine Hiller, MD, MPH, et al.

Introduction: In April 2013, the National Board of Medical Examiners (NBME) released an Advanced
Clinical Examination (ACE) in emergency medicine (EM). In addition to this new resource, CDEM
(Clerkship Directors in EM) provides two online, high-quality, internally validated examinations.
National usage statistics are available for all three examinations, however, it is currently unknown how
students entering an EM residency perform as compared to the entire national cohort. This information
may help educators interpret examination scores of both EM-bound and non-EM-bound students.
Objectives: The objective of this study was to compare EM clerkship examination performance
between students who matched into an EM residency in 2014 to students who did not. We made
comparisons were made using the EM-ACE and both versions of the National fourth year medical
student (M4) EM examinations.
Method: In this retrospective multi-institutional cohort study, the EM-ACE and either Version 1 (V1)
or 2 (V2) of the National EM M4 examination was given to students taking a fourth-year EM rotation
at five institutions between April 2013 to February 2014. We collected examination performance,
including the scaled EM-ACE score, and percent correct on the EM M4 exams, and 2014 NRMP
Match status. Student t-tests were performed on the examination averages of students who matched
in EM as compared with those who did not.
Results: A total of 606 students from five different institutions took both the EM-ACE and one of the
EM M4 exams; 94 (15.5%) students matched in EM in the 2014 Match. The mean score for EM-bound
students on the EM-ACE, V1 and V2 of the EM M4 exams were 70.9 (n=47, SD=9.0), 84.4 (n=36,
SD=5.2), and 83.3 (n=11, SD=6.9), respectively. Mean scores for non-EM-bound students were 68.0
(n=256, SD=9.7), 82.9 (n=243, SD=6.5), and 74.5 (n=13, SD=5.9). There was a significant difference
in mean scores in EM-bound and non-EM-bound student for the EM-ACE (p=0.05) and V2 (p<0.01)
but not V1 (p=0.18) of the National EM M4 examination.
Conclusion: Students who successfully matched in EM performed better on all three exams at the
end of their EM clerkship.