BackgroundImproving clinical reasoning education has been identified as an important strategy to reduce diagnostic error-an important cause of adverse patient outcomes. Clinical reasoning is fundamental to each specialty, yet the extent to which explicit instruction in clinical reasoning occurs across specialties in the clerkship years remains unclear.MethodThe Alliance for Clinical Education (ACE) Clinical Reasoning Workgroup and the Directors of Clinical Skills Courses (DOCS) Clinical Reasoning Workgroup collaborated to develop a clinical reasoning needs assessment survey. The survey questionnaire covered seven common clinical reasoning topics including illness scripts, semantic qualifiers, cognitive biases and dual process theory. Questionnaires were delivered electronically through ACE member organizations, which are primarily composed of clerkship leaders across multiple specialties. Data was collected between March of 2019 and May of 2020.ResultsQuestionnaires were completed by 305 respondents across the six organizations. For each of the seven clinical reasoning topics, the majority of clerkship leaders (range 77.4% to 96.8%) rated them as either moderately important or extremely important to cover during the clerkship curriculum. Despite this perceived importance, these topics were not consistently covered in respondents' clerkships (range 29.4% to 76.4%) and sometimes not covered anywhere in the clinical curriculum (range 5.1% to 22.9%).ConclusionsClerkship educators across a range of clinical specialties view clinical reasoning instruction as important, however little curricular time is allocated to formally teach the various strategies. Faculty development and restructuring of curricular time may help address this potential gap.

Background:Just-in-time training (JITT) occurs in the clinical context when learners need immediate guidance for procedures due to a lack of proficiency or the need for knowledge refreshment. The master adaptive learner (MAL) framework presents a comprehensive model of transforming learners into adaptive experts, proficient not only in their current tasks but also in the ongoing development of lifelong skills. With the evolving landscape of procedural competence in emergency medicine (EM), trainees must develop the capacity to acquire and master new techniques consistently. This concept paper will discuss using JITT to support the development of MALs in the emergency department. Methods:In May 2023, an expert panel from the Society for Academic Emergency Medicine (SAEM) Medical Educator's Boot Camp delivered a comprehensive half-day preconference session entitled "Be the Best Teacher" at the society's annual meeting. A subgroup within this panel focused on applying the MAL framework to JITT. This subgroup collaboratively developed a practical guide that underwent iterative review and refinement. Results:The MAL-JITT framework integrates the learner's past experiences with the educator's proficiency, allowing the educational experience to address the unique requirements of each case. We outline a structured five-step process for applying JITT, utilizing the lumbar puncture procedure as an example of integrating the MAL stages of planning, learning, assessing, and adjusting. This innovative approach facilitates prompt procedural competence and cultivates a positive learning environment that fosters acquiring adaptable learning skills with enduring benefits throughout the learner's career trajectory. Conclusions:JITT for procedures holds the potential to cultivate a dynamic learning environment conducive to nurturing the development of MALs in EM.

The presence of EUOF has been shown to impact the mental health of EM physicians in multiple ways.Those impacted reported differences in interactions with patients.

Education in Doctor of Medicine programs has moved towards an emphasis on clinical competency, with entrustable professional activities providing a framework of learning objectives and outcomes to be assessed within the clinical environment. While the identification and structured definition of objectives and outcomes have evolved, many methods employed to assess clerkship students’ clinical skills remain relatively unchanged. There is a paucity of medical education research applying advanced statistical design and analytic techniques to investigate the validity of clinical skills assessment. One robust statistical method, multitrait-multimethod matrix analysis, can be applied to investigate construct validity across multiple assessment instruments and settings. Four traits were operationalized to represent the construct of critical clinical skills (professionalism, data gathering, data synthesis, and data delivery). The traits were assessed using three methods (direct observations by faculty coaches, clinical workplace-based evaluations, and objective structured clinical examination type clinical practice examinations). The four traits and three methods were intercorrelated for the multitrait-multimethod matrix analysis. The results indicated reliability values in the adequate to good range across the three methods with the majority of the validity coefficients demonstrating statistical significance. The clearest evidence for convergent and divergent validity was with the professionalism trait. The correlations on the same method/different traits analyses indicated substantial method effect; particularly on clinical workplace-based assessments. The multitrait-multimethod matrix approach, currently underutilized in medical education, could be employed to explore validity evidence of complex constructs such as clinical skills. These results can inform faculty development programs to improve the reliability and validity of assessments within the clinical environment.

BackgroundDidactics play a key role in medical education. There is no standardized didactic evaluation tool to assess quality and provide feedback to instructors. Cognitive load theory provides a framework for lecture evaluations. We sought to develop an evaluation tool, rooted in cognitive load theory, to assess quality of didactic lectures. MethodsWe used a modified Delphi method to achieve expert consensus for items in a lecture evaluation tool. Nine emergency medicine educators with expertise in cognitive load participated in three modified Delphi rounds. In the first two rounds, experts rated the importance of including each item in the evaluation rubric on a 1 to 9 Likert scale with 1 labeled as "not at all important" and 9 labeled as "extremely important." In the third round, experts were asked to make a binary choice of whether the item should be included in the final evaluation tool. In each round, the experts were invited to provide written comments, edits, and suggested additional items. Modifications were made between rounds based on item scores and expert feedback. We calculated descriptive statistics for item scores. ResultsWe completed three Delphi rounds, each with 100% response rate. After Round 1, we removed one item, made major changes to two items, made minor wording changes to nine items, and modified the scale of one item. Following Round 2, we eliminated three items, made major wording changes to one item, and made minor wording changes to one item. After the third round, we made minor wording changes to two items. We also reordered and categorized items for ease of use. The final evaluation tool consisted of nine items. ConclusionsWe developed a lecture assessment tool rooted in cognitive load theory specific to medical education. This tool can be applied to assess quality of instruction and provide important feedback to speakers.

INTRODUCTION:Emergency medicine (EM) is a required clerkship for third-year medical students, and an elective EM acting internship (AI) is available to fourth-year students at our institution. The Society for Academic Emergency Medicine's (SAEM) National Emergency Medicine M4 Examination (EM-M4) is administered to students at the end of the EM AI experience. To prepare for the exam, students gain access to 23 practice tests available from SAEM. In this study we investigate the correlation between the number of practice tests taken and EM-M4 performance.METHODS:We collected data for EM-M4 and the US Medical Licensing Exam (USMLE) Step 2 Clinical Knowledge (CK) from students completing a MS4 EM clerkship in consecutive medical school classes from 2014-2017 at a private medical school. In addition, we collected data during the clerkship on the number of practice exams taken and whether a comprehensive practice exam was taken. We analyzed the study population three ways to determine whether the number of practice tests impacted final exam results: a binary distribution (1-11 or 12-23 tests taken); quaternary distribution (1-6, 7-12, 13-18, or 19-23 tests taken); and individual test variability (1,2,3,…22,23 tests taken). Complete data for 147 students was used for data analysis.RESULTS:The EM-M4 showed moderate (r = 0.49) correlations with USMLE Step 2 CK. There was no significant difference in EM-M4 performance in the binary analysis (P ≤ 0.09), the quaternary analysis (P ≤ 0.09), or the continuous variable analysis (P ≤ 0.52). Inclusion of a comprehensive practice test also did not correlate with EM-M4 performance (P ≤ 0.78).CONCLUSION:Degree of utilization of SAEM practice tests did not seem to correlate with performance on the EM-M4 examination at our institution. This could be due to many factors including that the question bank is composed of items that had poor item discrimination, possible inadequate coverage of EM curriculum, and/or use of alternative study methods. While further investigation is needed, if our conclusions prove generalizable, then using the SAEM practice tests is an extraneous cognitive load from a modality without proven benefit.

COVID necessitated the shift to virtual resident instruction. The challenge of learning via virtual modalities has the potential to increase cognitive load. It is important for educators to reduce cognitive load to optimize learning, yet there are few available tools to measure cognitive load. The objective of this study is to identify and provide validity evidence following Messicks’ framework for an instrument to evaluate cognitive load in virtual emergency medicine didactic sessions.

INTRODUCTION:An aortoenteric fistula (AEF) is an abnormal connection between the aorta and the gastrointestinal tract that develops due to a pathologic cause. It is a rare, but life-threatening, cause of gastrointestinal (GI) bleeding. Although no single imaging modality exists that definitively diagnoses AEF, computed tomography angiography (CTA) of the abdomen and pelvis is the preferred initial test due to widespread availability and efficiency.CASE REPORT:Many deaths occur before the diagnosis is made or prior to surgical intervention. We describe a case of a patient with a history of aortic graft repair who presented with active GI bleeding.CONCLUSION:Although CTA can make the diagnosis of AEF, it cannot adequately rule it out. In patients with significant GI bleeding and prior history of aortic surgery, vascular surgery should be consulted early on, even if CTA is equivocal.

INTRO:Medical schools sometimes need to adjust the length of third-year clinical clerkships. The literature surrounding the effects of shortened clerkships on student experience and performance is mixed.METHODS:Our medical school shortened the third year by an average of 20% per clerkship to accommodate a curricular re-design in 2018-2019. We examined test scores and measures of clinical performance as well as student experience in order to understand the impact of this change.RESULTS:Two hundred and eight students were included in the analysis, 104 in each cohort. No statistically significant differences were noted between cohorts on NBME subject examination results. There were no significant differences on Step 2 CK scores between the traditional curriculum cohort (M = 249.4, SD = 13.7) and shortened curriculum cohort (M = 248.7, SD = 15.8). Student performance on OSCE cases was similar. Similar percentages of students rated each clerkship either "good" or "excellent" in the traditional (77%) and shortened (78%) curriculum.CONCLUSION:There was no significant impact on student test scores after shortening the curriculum. Measures of student satisfaction and experience also remained stable, likely related to emphasis on retaining patient care experiences and streamlining of didactics. Curricular shortening during the third year of medical school was feasible and safe from the student perspective in our experience.

Several factors are known to affect the way clinical performance evaluations (CPEs) of medical students are completed by supervising physicians. We sought to explore the effect of faculty perceived “level of interaction” (LOI) on these evaluations. Our third-year CPE requires evaluators to identify perceived LOI with each student as low, moderate, or high. We examined CPEs completed during the academic year 2018–2019 for differences in (1) clinical and professionalism ratings, (2) quality of narrative comments, (3) quantity of narrative comments, and (4) percentage of evaluation questions left unrated. A total of 3682 CPEs were included in the analysis. ANOVA revealed statistically significant differences between LOI and clinical ratings (p ≤ .001), with mean ratings from faculty with a high LOI significantly higher than from faculty with a moderate or low LOI (p ≤ .001). Chi-squared analysis demonstrated differences based on faculty LOI and whether questions were left unrated (p ≤ .001), quantity of narrative comments (p ≤ .001), and specificity of narrative comments (p ≤ .001). Faculty who perceive higher LOI were more likely to assign that student higher ratings, complete more of the clinical evaluation and were more likely to provide narrative feedback with more specific, higher-quality comments.

Introduction Cognitive integration is required to perform clinical decision-making tasks, even in the preclinical curriculum of medical school. Simulation supports students' cognitive integration by providing practical application of basic science knowledge in a relevant clinical context. To address the need for integrative activities in our curriculum, we implemented a simulated clinic exercise with cases representing gastrointestinal diseases for first-year medical students. Methods Basic science and clinical skills course directors collaborated to design this simulated clinic event, during which student small groups rotated through a series of standardized patient encounters. During each encounter, one student performed the history and physical exam, following which the small group collaboratively developed a prioritized differential diagnosis. Afterwards, the gastroenterology course director debriefed students to highlight key learning points. We collected learner evaluation data following the event. Results Two hundred eighty first-year medical students participated in the simulated clinic in 2018 and 2019. Students rated these events as effective for learning about clinical features of the diseases presented and for reinforcing skills learned in the clinical skills course. Students agreed that the small-group format, pace, and duration were appropriate and that the problem-solving aspect was intellectually stimulating. The most effective aspects were opportunities to solidify illness scripts, apply knowledge to solve a problem, and encounter diseases in a realistic clinical context. Discussion This simulated clinic model effectively supported preclinical students' basic and clinical science integration to complete diagnostic reasoning tasks for gastrointestinal gastrointestinal conditions and was evaluated favorably by learners.

Weekly didactic conference in emergency medicine education has traditionally united residents and faculty for learning and fostered community within the residency program The global pandemic Coronavirus Disease-19 (COVID-19) has fueled a rapid transition to remote learning that has disrupted the typical in-person format To maintain ACGME1 educational experiences and requirements for residents in a safe manner, many residencies have moved to videoconferencing platforms such as Zoom?, Teams?, and WebEX ?

BACKGROUND:Residency applicants feel increasing pressure to maximize their chances of successfully matching into the program of their choice, and are applying to more programs than ever before.OBJECTIVE:In this narrative review, we examined the most common and highly rated factors used to select applicants for interviews. We also examined the literature surrounding those factors to illuminate the advantages and disadvantages of using them as differentiating elements in interviewee selection.METHODS:Using the 2018 NRMP Program Director Survey as a framework, we examined the last 10 years of literature to ascertain how residency directors are using these common factors to grant residency interviews, and whether these factors are predictive of success in residency.RESULTS:Residency program directors identified 12 factors that contribute substantially to the decision to invite applicants for interviews. Although United States Medical Licensing Examination (USMLE) Step 1 is often used as a comparative factor, most studies do not demonstrate its predictive value for resident performance, except in the case of test failure. We also found that structured letters of recommendation from within a specialty carry increased benefit when compared with generic letters. Failing USMLE Step 1 or 2 and unprofessional behavior predicted lower performance in residency.CONCLUSIONS:We found that the evidence basis for the factors most commonly used by residency directors is decidedly mixed in terms of predicting success in residency and beyond. Given these limitations, program directors should be skeptical of making summative decisions based on any one factor.

Background Although the concept of medical specialty competitiveness may seem intuitive, there are very little existing empirical data on the determinants of specialty competitiveness in USA. An understanding of the determinants of specialty competitiveness may inform career choices among students and their advisors. Specialty competitiveness correlates with availability and appeal. Methods This narrative review examines 2019 National Resident Matching Program (NRMP) data and the existing literature to define the determinants of specialty competitiveness. A statistical analysis of key elements of the 2019 NRMP data was performed. Results Using US senior applicant fill rate as a measure of competitiveness, medical specialty competitiveness follows general principles of supply and demand. The demand, or appeal, of a specialty correlates with several factors, including salary, prestige and lifestyle. Salary correlates strongly with US senior fill rate (r=0.78, p=0.001). Relatively few positions are available for the most competitive specialties in the NRMP match. The negative correlation between US senior fill rate and position availability is also strong (r=−0.85; p<0.0001). Conclusion A ‘competitive specialty’ correlates strongly with high earnings potential and limited position availability. In an ideal world, a student’s pursuit of a medical specialty should be guided by interest, qualifications and ability to succeed in that field. However, students must contend with the realities of competition created by the residency matching system.

Educators have been challenged to create assessments that are competency-based and grounded in accepted standards such as the entrustable professional activities (EPAs). The clinical performance evaluation (CPE) is a commonly utilized assessment modality, which allows multiple evaluators to provide feedback on a learner’s performance in the clinical workplace. In this paper, we describe the relevant principles that served as a guide as we developed a new CPE for medical students that fully incorporate EPAs. This may help ease the transition for other institutions looking to introduce a new student CPE.

INTRODUCTION:The objective of this study was to review and critically appraise the medical education literature pertaining to a flipped-classroom (FC) education model, and to highlight influential papers that inform our current understanding of the role of the FC in medical education.METHODS:A search of the English-language literature querying Education Resources Information Center (ERIC), PsychINFO, PubMed, and Scopus identified 296 papers related to the FC using either quantitative, qualitative, or review methods. Two reviewers independently screened each category of publications using previously established exclusion criteria. Eight reviewers then independently scored the remaining 54 publications using either a qualitative, quantitative, or review-paper scoring system. Each scoring system consisted of nine criteria and used parallel metrics that have been previously used in critical appraisals of education research.RESULTS:A total of 54 papers (33 quantitative, four qualitative, and 17 review) on FC met a priori criteria for inclusion and were critically appraised and reviewed. The top 10 highest scoring articles (five quantitative studies, two qualitative studies, and three review papers) are summarized in this article.CONCLUSION:This installment of the Council of Emergency Medicine Residency Directors (CORD) Academy Critical Appraisal series highlights 10 papers that describe the current state of literature on the flipped classroom, including an analysis of the benefits and drawbacks of an FC approach, practical implications for emergency medicine educators, and next steps for future research.

Lectures are a common instructional method in medical education. Understanding the cognitive processes and theories involved in learning is essential for lecturers to be effective. Cognitive load theory is one theory that is becoming increasingly recognized in medical education and addresses the appropriate use of one's working memory. Memory is essential to knowledge acquisition. Two types of memory can be considered, working memory (processing of information) and long-term memory (storage of information). Working memory has a limited capacity. Cognitive load refers to the amount of information processing activity imposed on working memory and can be divided into three domains: intrinsic, extraneous, and germane. By attending to cognitive load, educators can promote learning. This paper highlights various ways of improving cognitive load for learners during lecture-based instruction by minimizing extraneous load, optimizing intrinsic load, and promoting germane load.

To investigate whether starting the clerkship year in family medicine (FM), internal medicine (IM), pediatrics, or surgery influences NBME shelf and USMLE Step 2 CK examination performance. USMLE Step 1, Step 2 CK, and shelf examination scores for FM, IM, pediatrics, and surgery were collected. Sequences were selected on the following assignment criteria: rotation 1 (either FM or IM), rotation 5 (pediatrics), rotation 8 (surgery), rotation 1 (either pediatrics or surgery), and rotation 8 (IM). Multivariate analysis of covariance, with Step 1 as the covariate, was used to investigate rotation sequence on examination performance. Wilks’s statistic found no statistically significant effect of rotation sequence (starting the clerkship year in FM or IM) on the pediatrics, surgery, and Step 2 CK examinations (Λ = .95, F[3,51] = .93, p ≤ .432). Wilk’s statistic for the covariate (Step 1) was statistically significant (Λ = .488, F[3,51] = 17.827, p ≤ .001), indicating the two groups differ on Step 1 performance. Wilk’s statistic found no statistically significant effect of rotation sequence (starting the clerkship year in pediatrics or surgery) on the IM and Step 2 CK results (Λ = .925, F[2,75] = 3.036, p ≤ .054). Wilk’s statistic for the covariate (Step 1) was statistically significant (Λ = .309, F[2,75] = 83.915, p ≤ .001) indicating that the two groups differ on Step 1 performance. Starting the clerkship year in FM, IM, pediatrics, or surgery does not influence subsequent performance on shelf examinations or on Step 2 CK.