INTRODUCTION:Research on listening to podcasts while driving suggested no significant difference compared to undistracted listening. However, these studies were conducted in non-controlled driving environments, limiting the evaluation of the environment's impact. This study aimed to compare knowledge acquisition and retention among resident physicians and undergraduate students while listening to medical education podcasts in a controlled, simulator-based, driving environment versus an undistracted listening condition. METHODS:A randomized, crossover trial involved 19 residents and 22 undergraduate students from McMaster university and McMaster hospital. Participants listened to podcasts while driving in an immersive, high-fidelity motion simulator that mimics different driving environments: a high-distraction city environment and a low-distraction country environment. In the undistracted listening condition, participants listened to podcasts while being seated at a desk. Immediate and delayed recall tests after a month were administered, and data were analyzed using a 2x2 mixed ANOVA. RESULTS:There were no significant differences in knowledge acquisition (e.g., accuracy) between the undistracted, city driving, and country driving conditions (p > 0.05, η2 = 0.011). However, the country driving condition demonstrated slightly higher accuracy compared to the city driving condition in the immediate assessment condition (p < 0.05, η2 = 0.018). Medical expertise level (i.e., resident vs student) did not affect knowledge acquisition across different listening conditions (p > 0.05, η2 = 0.007). CONCLUSION:In a simulated environment, knowledge acquisition from a podcast is not compromised by the attention needed for driving a vehicle. The two distraction levels used in this experiment showed no significant interference with knowledge acquisition. This holds true regardless of participants' medical expertise. This study highlights the potential of incorporating podcasts into daily commuting to support ongoing education without requiring dedicated study time, enhancing both flexibility and efficiency in professional development.

The peer review process supports authors by providing feedback on manuscripts from external, expert readers. However, not all reviews are supportive. Some reviews are just painful. But just how painful are they? In this study, we set out to validate a matrix describing the levels of pain authors experience in response to the sting of peer reviewer comments. The study was carried out in two phases. In Phase 1, we developed a matrix combining two scales—i.e. the Suffering Scale and the Grind Gauge. The first categorises review‐induced pain across four levels, with Level 1 being the least pain and Level 4 the greatest pain. The second categorises the amount of work required by the author to respond to and address reviewer comments, with Level 1 being the least amount and Level 4 the greatest amount. In Phase 2, we tested the performance of the matrix by recruiting multiple, global study sites to provide performance data. This work resulted in the development and validation of the Reviewer‐Imposed Pain (RIP) matrix. A statistician analysed our data and assures us that the RIP matrix is now a validated tool. Our study shows that the pain associated with academic peer review affects physiologic, affective, and cognitive dimensions. This tongue‐in‐cheek paper pokes fun at the peer review process; however, the response from survey participants suggests that the process is not necessarily funny. Peer review is essential for advancing science; however, for these advancements to occur, peer reviewer comments need to be constructive. The RIP matrix encourages both authors and reviewers to reflect on the impact of reviewer comments. This is essential because, as previous research has illustrated and as Voltaire succinctly stated, pain is real.

Background & Need for Innovation:Synthesizing academic literature is a foundational skill in health professions education (HPE), enabling evidence-informed decision-making and continuous improvement. However, privileging one review type as the "gold standard" reinforces a narrow hierarchy of evidence, marginalizing alternative worldviews and synthesis approaches. Goal of Innovation:This innovation aimed to broaden understanding and legitimate use of diverse literature synthesis methods by developing an accessible knowledge mobilization portal to support learners, educators, and scholars across the HPE community. Steps Taken for Development and Implementation of Innovation:We developed LitR-Ex.com (Literature Reviews Explained) to showcase eight literature synthesis methods-the Literature Review Series (LRS). The Eco-Normalization Framework guided the design, implementation, and reflexive evaluation of the portal, aligning the innovation with contextual affordances and user needs. A collaborative, values-driven approach supported content co-creation, informed by lived experience, mutual trust, and a shared commitment to inclusivity. Evaluation of Innovation:The platform successfully launched and has been sustained through a network of contributors. Informal feedback and web analytics suggest positive engagement, and early adopters report its utility in teaching and research contexts. The innovation's resonance stems not only from its content but from the relationships and shared purpose underlying its development. Critical Reflection on Your Process:Key catalysts included: (1) friendship as an often-overlooked motivator in academic work; (2) trust and relationships that fostered momentum; and (3) a shared vision that anchored the innovation. These relational dimensions were as critical as the technical design in ensuring uptake and sustainability.

In this “When I Say…”, Pelaccia et al. deconstruct three common representations of intuition and its role in diagnostic reasoning in medicine

ObjectivesThe transition from residency to unsupervised practice challenges doctors to adapt to new environments and responsibilities. Past work has focused on how physicians acclimate to their new roles, raising questions about how residents might think proactively about transitions while still in training. This study explores senior emergency medicine (EM) residents' perspectives on preparedness for unsupervised practice and how they draw from training experiences to assess their evolving sense of preparedness.MethodsThe authors used a constructivist grounded theory approach, inviting all fourth-year EM residents from two residency programs to participate in semistructured interviews. Participants were asked to reflect on their preparedness for entering unsupervised practice and to imagine scenarios for which they felt unprepared. Two authors coded line by line using constant comparison, organizing data into codes and categories. The research team met to discuss relationships between codes, developing themes to theorize about the phenomenon of interest.ResultsSixteen residents were interviewed. The authors identified two overarching categories of themes. First, participants described individualized conceptualizations of preparedness, constructed from past workplace experiences and those they anticipated they would have in unsupervised practice. These conceptualizations emphasized drawing confidence from experience and developing adaptability to manage the uncertainties of medical practice. The second overarching category involved participants' efforts to gauge their own preparedness. To do so, they used interactions with others to assess their readiness to manage specific problems and made holistic appraisals across multiple experiences to assess their overall preparedness for unsupervised practice.ConclusionsTrainees draw from past experiences to forecast their abilities to manage the inevitable uncertainties of unsupervised practice. These conceptualizations of preparedness reflect a capability approach to training, with informed confidence and dynamic self-appraisal. These findings suggest potential learning goals of senior trainees and considerations for medical educators to consider when fostering trainees' capabilities for unsupervised practice.

Introduction: Despite the importance of peer review to publications, there is no generally accepted approach for editorial evaluation of a peer review’s value to a journal editor’s decision-making. The graduate medical education editors of the Western Journal of Emergency Medicine Special Issue in Educational Research & Practice (Special Issue) developed and studied the holistic editor’s scoring rubric (HESR) with the objective of assessing the quality of a review and an emphasis on the degree to which it informs a holistic appreciation for the submission under consideration. Methods: Using peer-review guidelines from several journals, the Special Issue’s editors formulated the rubric as descriptions of peer reviews of varying degree of quality from the ideal to the unacceptable. Once a review was assessed by each editor using the rubric, the score was submitted to a third party for blinding purposes. We compared the performance of the new rubric to a previously used semantic differential scale instrument. Kane’s validity framework guided the evaluation of the new scoring rubric around three basic assumptions: improved distribution of scores; relative consistency rather than absolute inter-rater reliability across editors; and statistical evidence that editors valued peer reviews that contributed most to their decision-making. Results: Ninety peer reviews were the subject of this study, all were assessed by two editors. Compared to the highly skewed distribution of the prior rating scale, the distribution of the new scoring rubric was bell shaped and demonstrated full use of the rubric scale. Absolute agreement between editors was low to moderate, while relative consistency between editor’s rubric ratings was high. Finally, we showed that recommendations of higher rated peer reviews were more likely to concur with the editor’s formal decision. Conclusion: Early evidence regarding the HESR supports the use of this instrument in determining the quality of peer reviews as well as its relative importance in informing editorial decision-making.

Background: Understanding the factors that contribute to diagnostic errors is critical if we are to correct or prevent them. Some scholars influenced by the default interventionist dual-process theory of cognition (dual-process theory) emphasise a narrow focus on individual clinician's faulty reasoning as a significant contributor. In this paper, we examine the validity of claims that dual process theory is a key to error reduction. Methods: We examined the relationship between a clinical experience (staff and resident physicians) and viewing time on accuracy for categorising chest X-rays (CXRs) and electrocardiograms (ECGs). In two studies, participants categorised images as normal or abnormal, presented at viewing times of 175, 250, 500 and 1000 ms, to encourage System 1 processing. Study 2 extended viewing times to 1, 5, 10 and 20 s to allow time for System 2 processing and a diagnosis. Descriptives and repeated measures analysis of variance were used to analyse the proportion of true and false positive rates (TP and FP) as well as correct diagnoses. Results: In Study 1, physicians were able to detect abnormal CXRs (0.78) and ECGs (0.67) with relatively high accuracy. The effect of experience was found for ECGs only, as staff physicians (0.71, 95% CI = 0.66-0.75) had higher ECG TP than resident physicians (0.63, 95% CI = 0.58-0.68) in Study 1, and staff had lower ECG FP (0.10, 95% CI = 0.03-0.18) than resident physicians (0.27, 95% CI = 0.20-0.33) in Study 2. In other comparisons, experience was equivocal for ECG FPs and CXR TPs and FPs. In Study 2, overall diagnostic accuracy was similar for both ECGs and CXRs, (0.74). There were small interactions between experience and time for TP in ECGs and FP in CXRs, which are discussed further in the discussion and offer insights into the relationship between processing and experience. Conclusion: Overall, our findings raise concerns about the practical application of models that link processing type to diagnostic error, or to specific diagnostic error reduction strategies.

PROBLEM:Early- and midcareer clinician educators often lack a local discipline-specific community of practice (CoP) that encourages scholarly activity. As a result, these faculty members may feel disconnected from other scholars.APPROACH:Academic Life in Emergency Medicine (ALiEM) piloted the Faculty Incubator. This longitudinal, asynchronous, online curriculum focused on developing a virtual CoP among 30 early- to midcareer medical educators (the "incubatees"), 8 core faculty mentors, and 10 guest mentors. The yearlong curriculum included 12 monthly modules focusing on core concepts in medical education scholarship. The initiative connected the incubatees with a virtual community of peers and mentors, with whom they completed multiple scholarly projects, sought mentorship, and engaged professionally. The authors used an online, closed, social media platform (Slack) to facilitate the exchange of ideas.OUTCOMES:In the inaugural year (March 2016-February 2017), the mentorship team facilitated exceptional levels of online engagement among incubatees. All participants (incubatees, core mentors, and guest mentors) shared 1,081 files and exchanged a total of 22,665 messages (approximately 62 per day). Of these, 3,036 (13.4%) were via open channels, 5,483 (24.2%) via small groups, and 14,146 (62.4%) via direct messages.NEXT STEPS:The ALiEM Faculty Incubator represents a proof of concept, and initial outcomes show that it is possible to engage an international group of early- to midcareer medical educators to create a vibrant online CoP. The Faculty Incubator leaders plan to determine whether this engaged group of health professions educators will increase their scholarly output as a result of this initiative.

Introduction Critical care, emergency medicine, and surgical trainees frequently perform surgical and Seldinger-technique tube thoracostomy, thoracentesis, and thoracic ultrasound. However, approaches to teaching these skills are highly heterogeneous. Over 10 years, we have developed a standardized, multidisciplinary curriculum to teach these procedures. Methods Emergency medicine residents, surgical residents, and critical care fellows, all in the first year of their respective programs, underwent training in surgical and Seldinger chest tube placement and securement, thoracentesis, and thoracic ultrasound. The curriculum included preworkshop instructional videos and 45-minute in-person practice stations (3.5 hours total). Sessions were co-led by faculty from emergency medicine, thoracic surgery, and pulmonary/critical care who performed real-time formative assessment with standardized procedural steps. Postcourse surveys assessed learners’ confidence before versus after the workshop in each procedure, learners’ evaluations of faculty by station and specialty, and the workshop overall. Results One hundred twenty-three trainees completed course evaluations, demonstrating stable and positive responses from learners of different backgrounds taught by a multidisciplinary group of instructors, as well as statistically significant improvement in learner confidence in each procedure. Over time, we have made incremental changes to our curriculum based on feedback from instructors and learners. Discussion We have developed a unique curriculum designed, revised, and taught by a multidisciplinary faculty over many years to teach a unified approach to the performance of common chest procedures to surgical, emergency medicine, and critical care trainees. Our curriculum can be readily adapted to the needs of institutions that desire a standardized, multidisciplinary approach to thoracic procedural education.

Phenomenon Imposter phenomenon (IP) is the feeling of inadequacy despite demonstrating external standards of success. Few studies have broadly examined the prevalence of IP in resident-physicians. This study assessed the prevalence of self-reported IP in resident-physicians, exploring the correlation of demographic risk factors and feelings of IP. Approach All residents, across all years of training and programs at McMaster University during the 2019-2020 academic year were recruited to complete a self-report survey. Survey items gathered demographic information and measured self-reported feelings of IP and Clance Imposter Phenomenon Scale (CIPS) scores. Findings 519 out of 977 (53.1%) individuals completed the survey. Measured by the CIPS, clinically significant IP occurred in 59.2% (n=307) of participants. After completing the CIPS, participants self-reported feelings of low (25.0%, n=130), medium (41.9%, n=218), high (19.0%, n=99), and intense (3.7%, n= 19) IP. 64.9% (n=337) of respondents felt they hid feelings of IP during residency. 62.4% (n=324) of respondents were unaware of resources available to them as they struggled with feelings of IP. Only female gender was associated with IP (p <0.001). Insights IP is highly prevalent across a broad range of residents, independent of clinical discipline and most demographics. Educators and administrators should attend to IP by normalizing the discussion of IP and ensuring adequate access to resources for support. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was approved by the Hamilton Integrated Research Ethics Board (protocol number: 4597). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Not Applicable All relevant data are within the manuscript and its Supporting Information files.

To the editor: We applaud the authors of "How to Give a Consultation and How to Get a Consultation" for bringing communication issues between specialists to the attention of the emergency medicine community. The communication skills that inform a consultation are defined by both the CanMEDS and the Accreditation Council for Graduate Medical Education (ACGME) competency frameworks. However, the educational science of a consultation is poorly studied. Hence, effective teaching strategies for both undergraduate and graduate medical education programs are potentially lacking.

PURPOSE:Emergency physicians (EPs) regularly manage multiple patients simultaneously, often making time-sensitive decisions around priorities for multiple patients. Few studies have explored physician cognition in multipatient scenarios. The authors sought to develop a conceptual framework to describe how EPs think in busy, multipatient environments.METHOD:From July 2014 to May 2015, a qualitative study was conducted at McMaster University, using a think-aloud protocol to examine how 10 attending EPs and 10 junior residents made decisions in multipatient environments. Participants engaged in the think-aloud exercise for five different simulated multipatient scenarios. Transcripts from recorded interviews were analyzed inductively, with an iterative process involving two independent coders, and compared between attendings and residents.RESULTS:The attending EPs and junior residents used similar processes to prioritize patients in these multipatient scenarios. The think-aloud processes demonstrated a similar process used by almost all participants. The cognitive task of patient prioritization consisted of three components: a brief overview of the entire cohort of patients to determine a general strategy; an individual chart review, whereby the participant created a functional patient story from information available in a file (i.e., vitals, brief clinical history); and creation of a relative priority list. Compared with residents, the attendings were better able to construct deeper and more complex patient stories.CONCLUSIONS:The authors propose a conceptual framework for how EPs prioritize care for multiple patients in complex environments. This study may be useful to teachers who train physicians to function more efficiently in busy clinical environments.

INTRODUCTION:Increasingly, medical training aims to develop physicians who are competent collaborators. Although interprofessional interactions are inevitable elements of medical trainees' workplace learning experiences, the existing literature lacks a cohesive model to conceptualise the learning potential residing in these interactions. METHODS:We conducted a critical review of the health professions and related educational literatures to generate an empirically and theoretically informed description of medical trainees' workplace interactions with other health professionals, including learning mechanisms and outcomes. Informed by Teunissen's conceptualisation of workplace learning, we highlight the individual, social and situated dimensions of learning from interprofessional workplace interactions. RESULTS:Workplace interactions between medical trainees and other health professionals tend to be brief, spontaneous, informal and often implicit without the predefined educational goals and roles that structure trainees' relationships with physician supervisors. Yet they hold potential for developing trainees' knowledge and skills germane to the work of a physician as well as building their capacity for collaboration. Our review identified a spectrum of learning theories helpful for examining what and how trainees learn from these interactions. Self-regulated learning theories focus attention on how learning depends on trainees interpreting and judging the cues offered by other health professionals. Sociocultural frameworks including the zone of proximal development and legitimate peripheral participation emphasise the ways other health professionals support trainees in performing tasks at the border of their abilities and facilitate trainees' participation in clinical work. Both the landscapes of practice theory and cultural historical activity theory highlight the influence of surrounding social, cultural and material environments. These theories are unified into cohesive model and demonstrated through an illustrative example. CONCLUSION:Interprofessional workplace interactions harbour a range of learning opportunities for medical trainees. Capitalising on their potential can contribute to training collaborative practice-ready physicians alongside traditional intra-professional interactions between physicians and merits future research.

Introduction Debriefing after simulation facilitates reflective thinking and learning. Eye-tracking augmented debriefing (ETAD) may provide advantages over traditional debriefing (TD) by leveraging video replay with first-person perspective. This multisite randomized controlled trial compared the impact of ETAD with TD (without eye-tracking and without video) after simulation on 4 outcomes: (1) resident metacognitive awareness (the primary outcome), (2) cognitive load (CL) of residents and debriefers, (3) alignment of resident self-assessment and debriefer assessment scores, and (4) resident and debriefer perceptions of the debriefing experience. Method Fifty-four emergency medicine residents from 2 institutions were randomized to the experimental (ETAD) or the control (TD) arm. Residents completed 2 simulation stations followed by debriefing. Before station 1 and after station 2, residents completed a Metacognition Awareness Inventory (MAI). After each station, debriefers and residents rated their CL and completed an assessment of performance. After the stations, residents were interviewed and debriefers participated in a focus group. Results There were no statistically significant differences in mean MAI change, resident CL, or assessment alignment between residents and debriefers. Debriefer CL was lower in the experimental arm. Interviews identified 4 themes: (1) reflections related to debriefing approach, (2) eye-tracking as a metacognitive sensitizer, (3) translation of metacognition to practice, and (4) ETAD as a strategy to manage CL. Residents reported that eye tracking improved the specificity of feedback. Debriefers relied less on notes, leveraged video timestamps, appreciated the structure of the eye-tracking video, and found the video useful when debriefing poor performers. Conclusions There were no significant quantitative differences in MAI or resident CL scores; qualitative findings suggest that residents appreciated the benefits of the eye-tracking video review. Debriefers expended less CL and reported less perceived mental effort with the new technology. Future research should leverage longitudinal experimental designs to further understand the impact of eye-tracking facilitated debriefing.

BackgroundThe consultation process, where a clinician seeks an opinion from another clinician, is foundational in medicine. However, the effectiveness of group diagnosis has not been studied.ObjectiveTo compare individual diagnosis to group diagnosis on two dimensions: group size (n=3 or 6) and group process (interactive or artificial groups).MethodologyThirty-six internal or emergency medicine residents participated in the study. Initially, each resident worked through four written cases on their own, providing a primary diagnosis and a differential diagnosis. Next, participants formed into groups of three. Using a videoconferencing platform, they worked through four additional cases, collectively providing a single primary diagnosis and differential diagnosis. The process was repeated using a group of six with four new cases. Cases were all counterbalanced. Retrospectively, nominal (ie, artificial) groups were formed by aggregating individual participant data into subgroups of three and six and analytically computing scores. Presence of the correct diagnosis as primary diagnosis or included in the differential diagnosis, as well as the number of diagnoses mentioned, was calculated for all conditions. Means were compared using analysis of variance.ResultsFor both authentic and nominal groups, the diagnostic accuracy of group diagnosis was superior to individual for both the primary diagnosis and differential diagnosis. However, there was no improvement in diagnostic accuracy when comparing a group of three to a group of six. Interactive and nominal groups were equivalent; however, this may be an artefact of the method used to combine data.ConclusionsGroup diagnosis improves diagnostic accuracy. However, a larger group is not necessarily superior to a smaller group. In this study, interactive group discussion does not result in improved diagnostic accuracy.

Postgraduate medical education is an essential societal enterprise that prepares highly skilled physicians for the health workforce. In recent years, PGME systems have been criticized worldwide for problems with variable graduate abilities, concerns about patient safety, and issues with teaching and assessment methods. In response, competency based medical education approaches, with an emphasis on graduate outcomes, have been proposed as the direction for 21st century health profession education. However, there are few published models of large-scale implementation of these approaches. We describe the rationale and design for a national, time-variable competency-based multi-specialty system for postgraduate medical education called Competence by Design. Fourteen innovations were bundled to create this new system, using the Van Melle Core Components of competency based medical education as the basis for the transformation. The successful execution of this transformational training system shows competency based medical education can be implemented at scale. The lessons learned in the early implementation of Competence by Design can inform competency based medical education innovation efforts across professions worldwide.

BACKGROUND:Accurate diagnosis in emergency medicine (EM) is high stakes and challenging. Research into physicians' clinical reasoning has been ongoing since the late 1970s. The dual-process theory has established itself as a valid model, including in EM. It is based on the distinction between two information-processing systems. System 1 rapidly generates one or more diagnostic hypotheses almost instantaneously, driven by experiential knowledge, while System 2 proceeds more slowly and analytically, applying formal rules to arrive at a final diagnosis. METHODS:We reviewed the literature on dual-process theory in the fields of cognitive science, medical education and emergency medicine. RESULTS AND CONCLUSION:The literature reflects two prominent interpretations regarding the relationship between the fast and slow phases and these interpretations carry very different implications for the training of clinical learners. One interpretation, prominent in the EM community, presents it as a "check-and-balance" framework in which most diagnostic error is caused by cognitive biases originating within System 1. As a result, EM residents are frequently advised to deploy analytical (System 2) strategies to correct such biases. However, such teaching approaches are not supported by research into the nature of diagnostic reasoning. An alternative interpretation assumes a harmonious relationship between Systems 1 and 2 in which both fast and slow processes are driven by underlying knowledge that conditions performance and the occurrence of errors. Educational strategies corresponding to this alternative have not been explored in the EM literature. In this paper, we offer proposals for improving the teaching and learning of diagnostic reasoning by EM residents.