BackgroundAlthough people with disabilities account for 40% of annual visits to U.S. emergency departments (EDs), physicians receive minimal training on caring for this population. The objective of this study was to explore emergency medicine (EM) resident preparedness and attitudes in caring for patients with disabilities and ease of providing accommodations in the ED.MethodsWe developed and administered a cross-sectional 32-item survey to EM residents in the United States from November 2023 to January 2024. The primary outcomes were (1) self-reported preparedness in caring for patients with disabilities, (2) attitudes toward individuals with disabilities, and (3) ease of providing accommodations. Frequency distributions for each item and associations between personal demographics and survey responses are reported.ResultsA total of 209 participants completed the survey. The majority were female (51%) and White (70%). A minority (9.5%) identified with having a disability. Residents felt prepared to care for patients with physical disabilities (77%) and chronic illnesses (93%) and less prepared with patients who are nonverbal (34%) or blind/visual impairment (45%). Most residents (99%) believed that patients with disabilities deserved equitable care; however, most thought patients with disabilities had a poor quality of life (75%). Residents reported difficulty providing accommodations to patients who are blind/visual impairment (54%) and Deaf/hard of hearing (45%). For those who encountered acute care plans/health care passports for accommodations, 88% found them useful. The majority of residents (80%) desired improved disability health education, specifically on sensory and intellectual/developmental disabilities, communication skills training, and resources for accommodations.ConclusionsEM residents report feeling less prepared to care for patients with sensory disabilities and intellectual/developmental disabilities and report difficulty obtaining histories, performing physical examinations, and providing accommodations to this population. Implementing curricula focusing on disability health may improve skills, reduce bias, and provide more equitable care.

INTRODUCTION:Applying to emergency medicine (EM) residency programs is costly. In the past several years, the EM residency application process has undergone multiple changes in recommendations regarding away rotations and interview format, primarily but not solely driven by COVID-19 restrictions. To date, little is known about the financial impact of these changes on EM applicants. This study assesses recent trends and changes in the costs of the EM residency application. METHODS:We analyzed EM applicant survey data from the Texas STAR (Seeking Transparency in Application to Residency) database from 2019-2024. Application cycles were grouped into three time periods: pre-pandemic (2019-2020), pandemic (2021-2022), and post-pandemic (2023-2024). Applicants' self-reported data for application fees, away rotation costs, interview costs, and total expenses were analyzed. We conducted Kruskal-Wallis testing to evaluate differences in expense-related variables across the three time periods. We performed post-hoc analysis using the Dunn test if significant differences were detected. RESULTS:This study included 3,495 EM applicants, which represents 8.4% of the total 41,497 Texas STAR survey respondents from 2019-2024. Average per-applicant total costs were $5,412, $2,076, and $3,156 in the pre-, during-, and post-pandemic application cycles. Self-reported total applicant expenses decreased between the pre- and pandemic period and increased from the pandemic and post-pandemic period (P < .01). Applicants had the lowest overall costs in 2021. Away rotation, second look, application costs, interview travel and lodging, and virtual interview costs all reached their lowest levels during the pandemic period (P < .01). In the post-pandemic period, travel and lodging costs were higher than pre- and during pandemic levels, while interview costs remained lower due to the continued use of virtual interviews (P < .01). Applicants from the Western Region of the US saw the highest total costs compared to the Northeast, which saw the lowest. CONCLUSION:The total expenses reported by medical students applying to EM residency programs were significantly reduced during the pandemic, compared to other years. Some expenses, notably away rotation and second look and application costs, have risen post-pandemic. To help reduce the financial burden of the EM residency process, the continued use of virtual interviews is an opportunity for cost savings.

Background:The quality of and access to care by lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender diverse (LGBTQIA+) patients is often compromised by physician knowledge deficits, bias, and inadequate training in LGBTQIA+ health. Emergency medicine physicians must be prepared to care for LGBTQIA+ patients, but there is a lack of standardized training in LGBTQIA+ health across emergency medicine residencies. We sought to assess current practices and perform a needs assessment of LGBTQIA+ health teaching across a sample of emergency medicine residencies. Methods:Residents from five geographically diverse emergency medicine residencies in the United States were invited to complete an online Qualtrics survey between April 2024 and June 2024. The survey included questions regarding the scope of LGBTQIA+ health exposure in residency as well as delivery preferences to improve LGBTQIA+ health teaching within residency curricula. Results:One hundred residents across the five programs participated in the survey (37% response rate). Most residents reported some exposure to gender-affirming language practices and LGBTQIA+ health disparities. Topics with the least reported coverage were pediatric considerations, legal considerations, and taking an organ inventory. Overall, participants were more comfortable performing clinical care for sexual minority patients than gender minority patients. Suggestions for improving LGBTQIA+ health education emphasized the necessity of incorporating LGBTQIA+ health into the core curriculum and including LGBTQIA+ community members and patients into curricular design and delivery. Conclusions:The results of this study can guide future educational assessment and curricular development efforts to improve LGBTQIA+ health content delivery during emergency medicine residency training.

Background:The standardized letter of evaluation (SLOE) for emergency medicine (EM) is a well-established tool for residency selection. While previous work characterizes the utility and outcomes related to SLOE use, less is known about SLOE authorship patterns and trends. Objective:The objective was to measure the prevalence of group SLOEs in EM over time, characterize the role groups represented in group SLOEs, and compare the rating practices of groups of authors versus single authors. Methods:SLOE data from 2016 through 2021 were obtained from the CORD database. An algorithm was developed to process SLOE author fields to accomplish three tasks: (1) determine whether the SLOE was written by an individual or a group, (2) determine the number of named letter writers on group SLOEs, and (3) identify roles of individuals listed on group SLOEs. A total of 150 SLOEs were randomly selected for review by the study team to use as a standard to which algorithm performance was compared. Mean ratings were compared for (1) individual versus group SLOEs and (2) individual SLOEs from clerkship directors (CDs) versus others. Results:A total of 40,218 SLOEs met inclusion criteria. The algorithm performed well in detecting group SLOEs, authors, and titles. Institutions submitting only SLOEs written by a group of authors increased from 31.4% to 54.5%. Authors per group SLOE increased from 3.4 in 2016 to 4.0 in 2021. Mean ratings were slightly higher in individual SLOEs compared to group SLOEs. Individual SLOEs from non-CDs had higher ratings compared to those from CDs. Conclusions:The proportion of SLOEs authored by groups increased over the study interval. Grading practices are similar between group SLOEs and individual SLOEs authored by CDs. Individual SLOEs from non-CDs had slightly higher ratings compared to the other groups.

Program signals were introduced to the emergency medicine (EM) residency application process during the 2022–2023 and 2023–2024 application cycles, allowing applicants to express interest in specific programs. Despite widespread adoption, the relationship between signal usage and applicant outcomes remains poorly understood. This study evaluates patterns of signal utilization and their association with interview offers and match outcomes during the initial implementation in EM. We conducted a retrospective analysis of the Texas Seeking Transparency in Application to Residency (Texas STAR) database, examining US allopathic and osteopathic senior medical students applying to EM residency programs during two application cycles (2022–2023 and 2023–2024). We analyzed program signal (PS) distribution patterns using χ 2 testing and employed multivariable logistic regression to assess the relationship between PS usage and both interview offers and match outcomes. The study included 967 EM applicants across two application cycles (478 in 2022–2023, 489 in 2023–2024), who sent 1919 signals in 2022–2023 and 3170 in 2023–2024. Signal distribution was highly concentrated, with the top 10% of programs receiving 35% of all signals in both application cycles. Interview yield was higher at signaled programs (2023 cycle: 76.3%, 2024 cycle: 78.9%) compared to programs overall (2023 cycle: 51.3%, 2024 cycle: 43.5%). In logistic regression analysis, sending a program signal was associated with increased odds of receiving an interview offer (2023 cycle: OR 4.40, 95% CI 3.90–4.92; 2024 cycle: OR 3.79, 95% CI 3.42–4.14), and matching after interviewing (2023 cycle: OR 5.13, 95% CI 4.08–6.47; 2024 cycle: OR 4.94, 95% CI 3.98–6.15). Program signals are associated with improved odds of receiving interviews and matching at EM programs. Future studies should investigate how signals affect the likelihood of receiving interview offers for applicants across different levels of competitiveness.

The authors declare no conflicts of interest. Data S1: Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Background Standardized Letters of Evaluation (SLOEs) are an important part of resident selection in many specialties. Often written by a group, such letters may ask writers to rate applicants in different domains. Prior studies have noted inflated ratings; however, the degree to which individual institutions are “doves” (higher rating) or “hawks” (lower rating) is unclear. Objective To characterize institutional SLOE rating distributions to inform readers and developers regarding potential threats to validity from disparate rating practices. Methods Data from emergency medicine (EM) SLOEs between 2016 and 2021 were obtained from a national database. SLOEs from institutions with at least 10 letters per year in all years were included. Ratings on one element of the SLOE—the “global assessment of performance” item (Top 10%, Top Third, Middle Third, and Lower Third)—were analyzed numerically and stratified by predefined criteria for grading patterns (Extreme Dove, Dove, Neutral, Hawk, Extreme Hawk) and adherence to established guidelines (Very High, High, Neutral, Low, Very Low). Results Of 40 286 SLOEs, 20 407 met inclusion criteria. Thirty-five to 50% of institutions displayed Neutral grading patterns across study years, with most other institutional patterns rated as Dove or Extreme Dove. Adherence to guidelines was mixed and fewer than half of institutions had Very High or High adherence each year. Most institutions underutilize the Lower Third rating. Conclusions Despite explicit guidelines for the distribution of global assessment ratings in the EM SLOE, there is high variability in institutional rating practices.

BACKGROUND:Workload in the emergency department (ED) fluctuates and there is no established model for measurement of clinician-level ED workload. OBJECTIVE:The aim of this study was to measure perceived ED workload and assess the relationship between perceived workload and objective measures of workload from the electronic medical record (EMR). METHODS:This study was conducted at a tertiary care, academic ED from July 1, 2020 through April 13, 2021. Attending workload perceptions were collected using a 5-point scale in three care areas with variable acuity. We collected eight EMR measures thought to correlate with perceived workload. EMR values were compared across areas of the department using ANOVA and correlated with attending workload ratings using linear regression. RESULTS:We collected 315 unique workload ratings, which were normally distributed. For the entire department, there was a weak positive correlation between reported workload perception and mean percentage of inpatient admissions (r = 0.23; p < 0.001), intensive care unit admissions (r = 0.2; p < 0.001), patient arrivals per shift (r = 0.14; p = 0.017), critical care billed visits (r = 0.22; p < 0.001), cardiopulmonary resuscitation code activations (r = 0.2; p < 0.001), and level 5 visits (r = 0.13; p = 0.02). There was weak negative correlation for ED discharges (r = -0.23; p < 0.001). Several correlations were stronger in individual care areas, including percent admissions in the lowest-acuity area (r = 0.43; p = 0.033) and patient arrivals in the highest-acuity area (r = 0.44; p < .01). No significant correlation was found in any area for observation admissions or trauma activations. CONCLUSIONS:In this study, EMR measures of workload were not closely correlated with ED attending physician workload perception. Future study should examine additional factors contributing to physician workload outside of the EMR.

Impact: Residents completed an anonymous postconference survey which used a 5-point Likert scale.100% reported the event was educational, appropriately timed, and covered EM-relevant topics.Residents reported enjoyment in the stations between 4.3-4.75/ 5 on the Likert scale highlighting a Kirkpatrick level 1 impact.Learners report increased confidence in skills in airway procedures, fast track procedures, leadership, communication, and handoff demonstrating Kirkpatrick level 2 impact.We hope this project will continue annually and demonstrate higher levels of impact for the learners.

The Next Accreditation System implemented by the Accreditation Council for Graduate Medical Education introduced specialty-specific Milestones for the 6 core competencies in 2013.1 Recently, a 2.0 version of the Milestones harmonized the subcompetencies across specialties, in part to encourage collaboration and sharing of assessment tools and best practices.2 Specialties created unique subcompetencies for Patient Care and Medical Knowledge, while a standardized framework was used to craft the remaining 4 competencies.2 These harmonized subcompetencies in Milestones 2.0 represent shared language, themes, and goals that are consistent across specialties, decreasing the variability seen in the first iteration.While the Milestones provide a guide to competency expectations, residency programs across specialties still struggle with remediation—particularly related to Professionalism and Interpersonal and Communication Skills (ICS).3,4 In 2016, Regan et al analyzed the first iteration of the Professionalism and ICS Milestones and published a toolkit of remediation methods for these core competencies.5 With the 2.0 version of harmonized Milestones, the opportunity to share resources and strategies for remediation of Professionalism and ICS across specialties becomes more readily feasible. The objective of this Perspective is to identify the common Milestone 2.0 themes among Professionalism and ICS subcompetencies, to create an updated compilation of remediation tools, and to provide an approach for developing a remediation plan for Professionalism and ICS.Following the methodology of Regan et al in 2016,5 the authors performed a content analysis of the version 2.0 Professionalism and ICS subcompetencies for 13 core specialties: anesthesiology, emergency medicine, family medicine, internal medicine, neurology, obstetrics and gynecology, ophthalmology, orthopedics, pathology, pediatrics, psychiatry, radiology, and surgery. All authors independently reviewed each specialty's subcompetencies and identified themes. Reviewer disagreements were resolved through group review to achieve consensus.Forty-six individual subcompetency themes were identified (21 Professionalism and 25 ICS). Specialties differed in the number of subcompetencies devoted to Professionalism and ICS, but the authors were able to collate these 46 individual themes into 20 common themes (8 Professionalism and 12 ICS). The group agreed to focus the assessment on levels 1 through 4, as level 5 achievements are not required for graduation but are aspirational and thus do not require remediation if not achieved.5 Themes present in most specialties (ie, at least 7 of 13) were deemed to be of greatest value to educators across specialties. One theme (confidence and self awareness of limits) was present in 6 specialties but was included as the authors believed that resources for remediating this subcompetency would be valuable. These 20 themes are included in online supplementary data tables 1 and 2.To identify remediation methods for deficiencies in the 20 common themes, a professional medical librarian trained in systematic reviews helped create a literature search for relevant English-language articles published between 2000 and 2022. The strategy utilized Boolean operators and keywords, derived from the shared subcompetency themes described in online supplementary data tables 1 and 2, along with the search protocol, also available in the online supplementary data. There were 403 citations for Professionalism and 440 citations for ICS identified. Authors screened the resulting titles and abstracts and extracted full text articles that pertained to the remediation of Professionalism or ICS in medical trainees for review.Based on this literature review, their experience with remediation in Professionalism and ICS, and the previous toolkit,5 the authors aggregated specific methods for remediation in the identified shared subcompetency themes for both Professionalism (online supplementary data Table 1) and ICS (online supplementary data Table 2). These suggested methods are intended for use as a guide, with the understanding that each plan must be tailored for the specific specialty, appropriate for the lapse requiring remediation, and personalized for each trainee. Methods without specific references are drawn from the expert opinion of the authors, who share over 75 years of collective experience in residency program and institutional graduate medical education (GME) leadership. Although there are limited outcome data for the aggregated methods, the authors' consensus is that the provided references are valuable as potential resources for educators developing remediation plans for learners struggling with Professionalism and ICS.This toolkit will allow educators to identify resources to incorporate into improvement plans for trainees performing below expectations in Professionalism or ICS. As a critical first step, faculty must explore any mental health or physical illness, alcohol or other substance use disorders, or external stressors that could be contributing to the perceived lapses. If identified, the program director (PD) should refer the trainee for counseling or care, per program and institutional policies. If those issues are not assessed as contributing factors, then a remediation plan that includes input from resident self-reflection can be implemented.As opposed to the first iteration, the harmonized Milestones allow for sharing of assessment and remediation methods across all specialties. As each trainee is unique and has their own challenges, learning plans may be developed based on individual needs and local availability of resources. Once deficiencies are identified, program leadership may refer to online supplementary data tables 1 and 2 to review strategies and resources corresponding to subcompetency themes and create improvement plans.For context, we walk through a hypothetical scenario. A PD receives several complaints from consultants that a resident frequently provides unclear consultation requests and does not consistently follow recommendations. Additionally, recent peer and faculty evaluations report that the resident is less engaged with the team, arrives late and unprepared for rounds, appears tired, and is irritable.The resident's Milestone performance is reviewed by the PD and Clinical Competency Committee (CCC). It is determined that the resident is below expectations in areas of Professionalism and ICS. Referring to online supplementary data table 1, the PD maps the concerns raised in peer and faculty evaluations to the Self-Awareness and Well-Being subcompetency within Professionalism and identifies "recognizes and promotes personal and professional well-being, including wellness, burnout, fatigue, and stress-recognition and mitigation" as the pertinent Milestone theme. Regarding the consultant communication issue, using online supplementary data table 2, they map the concern to the Interprofessional and Team Communication subcompetency within ICS and identify "requests consults effectively and integrates recommendations" as the pertinent Milestone theme.After requesting that the resident reflect on the identified Professionalism and ICS concerns, the PD and CCC review the suggested resources for the themes provided in the online supplementary data Tables, and, together with the resident, develop an individualized performance improvement strategy.For the Professionalism concerns, the resident will:Meet with program leadership to discuss professional appearance, punctuality, and wellness techniques.Use screening tools and the institution's employee assistance program to assess and monitor progress.Participate in wellness education, including development and presentation of content during a didactic session.For the ICS concerns:The resident will review selected literature on effective consultation and discuss with the faculty advisor a standard approach that they will utilize.The PD will arrange direct observation and feedback by faculty during consultant interactions.Together, the PD and resident will request consultants' feedback regarding interactions and will review with a faculty advisor or PD.For monitoring, the PD schedules monthly check-ins with the resident to track progress and confidentially alerts supervising physicians that their feedback on the consultation issues will be solicited monthly for 2 to 3 months, or until feedback is universally supportive of successful remediation. The resident agrees to this remediation plan, which is enacted immediately.Harmonizing the Professionalism and ICS Milestones provides educators an opportunity to identify, collate, and share resources for remediation across specialties. With the specific activities and monitoring methods described, program leaders can use our updated recommendations as a guide to remediate Professionalism and ICS. It remains our hope that targeted remediation strategies will be developed for Milestones under other subcompetencies. Collaboration within the GME community to develop assessment tools and remediation strategies for the version 2.0 harmonized Milestone subcompetencies, and to study the efficacy of these strategies, should be the standard.The authors would like to thank Katie Lobner, MLIS, for her assistance in executing the literature search for this manuscript.The online supplementary data contains the tables from the study and the literature search protocol.Disclaimer: Dr. Linda Regan is the current Chair of the Review Committee for Emergency Medicine at the Accreditation Council for Graduate Medical Education (ACGME). Dr. Tiffany Murano is a member of the Review Committee for Emergency Medicine at the ACGME. Drs. Regan and Murano's contributions here are their own and reflect their work and opinions and should not be viewed as an endorsement from the ACGME.

Dr. Carrie Walsh: Today's case is a case of a 55-year-old woman who presented with sudden onset, 10/10 chest pain, radiating to the left shoulder, back and jaw, which started approximately 1 h prior to presentation. The patient was on shift as a nurse in a rehabilitation facility when the pain began. The emergency medical services (EMS) crew reported that her colleagues took a blood pressure and when it was found to be elevated they administered the home dose of her antihypertensive, amlodipine. She denied accompanying shortness of breath, diaphoresis, and nausea. The patient does not take any hormonal supplements and denied recent prolonged periods of immobilization or recent travel.

Dr. Carrie Walsh: Today's case is a case of a 55-year-old woman who presented with sudden onset, 10/10 chest pain, radiating to the left shoulder, back and jaw, which started approximately 1 h prior to presentation. The patient was on shift as a nurse in a rehabilitation facility when the pain began. The emergency medical services (EMS) crew reported that her colleagues took a blood pressure and when it was found to be elevated they administered the home dose of her antihypertensive, amlodipine. She denied accompanying shortness of breath, diaphoresis, and nausea. The patient does not take any hormonal supplements and denied recent prolonged periods of immobilization or recent travel.

Background:Narrative analysis and reflection have been found to support professional identity formation (PIF) and resilience among medical students. In the emergency department, students have used reflective practice to process challenging clinical experiences, such as ethical dilemmas or moral distress. An online discussion board, however, has not been described as a curricular component of emergency medicine (EM) rotations. The objective of this educational innovation was to support medical students in an EM clinical rotation via an online discussion board for reflecting on and debriefing clinical experiences with faculty and peers. Methods:Fifty-two medical students enrolled in the pass/fail EM elective between May 13, 2019, and October 30, 2020. Each cohort of six students took part in a cohort-specific discussion using the Canvas learning management system. Students were encouraged to post about any observations, reflections, or emotions after their shifts. Faculty course directors responded to each post using concepts of debriefing, coaching, and trauma-informed teaching. Results:Over 18 months, 49 of 52 (94%) students participated in the discussion board. Of 346 total posts, half were by students, and the other half were faculty responses. Students posted 3.27 times each, on average. Students rarely raised questions about scientific knowledge content, fact-based aspects of patient care, or specific skills. Rather, they often posted about intensely affective reactions to experiences that left them with complex emotions. Upon review of posts by the course directors, the majority (54%) of students' posts contained a range of affective responses. Students appreciated faculty responses and supported each other in their written responses to peers. Conclusions:An online discussion board can be used successfully for asynchronous reflective practice to debrief clinical experiences during an EM rotation, if designed incorporating faculty and peer support using trauma-informed teaching principles to bolster well-being and PIF.

Study Objective: Procedural competency is essential to the practice of emergency medicine. However, there are limited data quantifying emergency department procedural volumes to inform the work of educators and credentialing bodies. In this study, we characterize procedural scope and volume in a regional health care system and compare rates between practice settings and over time. Methods: Cross-sectional data were acquired from electronic medical records of a regional health care system from March 2017 through February 2022. Nonspecific entries, esoteric procedures, and nonprocedural clinical skills were excluded. Procedural rates were compared: (1) between academic and community hospitals, (2) across study years, and (3) across seasons. Analyses were repeated for pediatric encounters, and with study year 4 removed to assess the influence of the first year of the coronavirus disease 2019 pandemic on results. Results: There were 131,976 instances of 40 qualifying procedures in 1,979,935 unique visits across 9 EDs. Several high-acuity procedures had similar rates in academic and community settings, including cardiac pacing, cricothyrotomy, and lateral canthotomy. Year-over-year procedural rates were stable or increasing for most procedures, with a notable exception of lumbar puncture. Most procedures did not have significant seasonal variation, and most findings were stable when study year 4 was removed from the analysis. Conclusion: All procedures were performed in all settings and rates of several emergent procedures were similar in both settings, underscoring the importance of broad procedural competence for all emergency physicians. Educators and credentialing organizations can use these data to inform decisions regarding curriculum design and certification requirements.

Introduction: Leadership positions occupied by women within academic emergency medicine have remained stagnant despite increasing numbers of women with faculty appointments. We distributed a multi-institutional survey to women faculty and residents to evaluate categorical characteristics contributing to success and differences between the two groups. Methods: An institutional review board-approved electronic survey was distributed to women faculty and residents at eight institutions and were completed anonymously. We created survey questions to assess multiple categories: determination; resiliency; career support and obstacles; career aspiration; and gender discrimination. Most questions used a Likert five-point scale. Responses for each question and category were averaged and deemed significant if the average was greater than or equal to 4 in the affirmative, or less than or equal to 2 in the negative. We calculated proportions for binary questions. Results: The overall response rate was 55.23% (95/172). The faculty response rate was 54.1% (59/109) and residents’ response rate was 57.1% (36/63). Significant levels of resiliency were reported, with a mean score of 4.02. Childbearing and rearing were not significant barriers overall but were more commonly reported as barriers for faculty over residents (P <0.001). Obstacles reported included a lack of confidence during work-related negotiations and insufficient research experience. Notably, 68.4% (65/95) of respondents experienced gender discrimination and 9.5% (9/95) reported at least one encounter of sexual assault by a colleague or supervisor during their career. Conclusion: Targeted interventions to promote female leadership in academic emergency medicine include coaching on negotiation skills, improved resources and mentorship to support research, and enforcement of safe work environments. Female emergency physician resiliency is high and not a barrier to career advancement.

A myotonic dystrophy (DM) family is described in which discordant DM phenotypes were found in the children of two affected sisters with similar CTG expansion and clinical manifestations. In this family, congenital as well as early severe childhood and later childhood onset DM coexist. This observation strengthens the limited ability of lymphocytes CTG repeat number analysis in predicting genotype-phenotype correlations in DM patients.

Study objective: To characterize the emergency medicine resident physician workforce and the residency programs training them. Methods: We identified emergency medicine residents in the 2020 American Medical Association (AMA) Physician Masterfile, analyzed demographic information, mapped both county-level population-adjusted and hospital referral region densities, and compared 2020 versus 2008 resident physician densities. We also analyzed all Accreditation Council for Graduate Medical Education (ACGME)-accredited emergency medicine residency programs from 2013 to 2020, mapped state-level population -adjusted densities, and identified temporal trends in program location and state-level program densities. All population-adjusted densities were calculated using the US Census Bureau resident population estimates. Results: There were 6,993 emergency medicine residents in the 2020 AMA dataset with complete information. Most of them (98%) were in urban areas. Compared with 2008, per 100,000 US population, this represents disproportionate increases in urban areas (total [0.5], urban [0.5], large rural [0.2] and small rural [0.05]). We further identified 160 (2013) to 265 (2020) residency programs using the ACGME data. The new programs were 3-year training programs that were disproportionately added to states with an already higher number of programs (Florida [5 to 19], Michigan [11 to 25], New York [21 to 31], Ohio [9 to 18], Pennsylvania [12 to 21], California [14 to 22]). Conclusion: The number of emergency medicine residency programs has increased; most new programs were added to the states that already had emergency medicine residency programs. There is an emergency physician "desert" in the rural United States, lacking both residents and residency training programs. This analysis provides essential context to the ongoing conversation about the future of the emergency physician workforce.

Introduction Burnout rates for emergency medicine residents are high. One intervention and initiative to enhance wellness and address burnout is the resident retreat. Retreats have multiple formats and are often designed with an emphasis on social events. This longitudinal retreat curriculum for a three-year residency training program was designed emphasizing rest, a step away from what is familiar, and reflection. Methods Individual resident retreats were designed for each year of postgraduate training. The agenda for each is organized and intentional. Activities focused on personal well-being, self-reflection, team building, professional development, and physical activities are coupled with topics unique to class year roles and responsibilities. Retreats are held away from the hospital establishing a separation from the workplace. Results The retreat program has been sustainable for almost decades with trainees evaluating it highly. Faculty and residents enthusiastically participate in the program and consider it a fundamental part of the residency; 93.75% of residents surveyed strongly agreed that the retreats benefit their training while 94.2% strongly agreed that retreats increased their enthusiasm for training. Conclusions An emergency medicine resident retreat program focusing on unique elements for each post-graduate year is achievable and sustainable in an emergency medicine residency program. Over time, the retreat has become an integral part of the residency experience with positive experiences for both faculty and trainees.