Introduction:Competency-based medical education (CBME) is a learner-centric and outcomes-based approach to medical training that is essential to improve patient care. Coaching and individualized learning have been proposed to catalyze a core component of CBME, "competency-focused instruction". While coaching and individualized learning hold great theoretical and conceptual benefit to drive future educational initiatives, there remains a paucity of literature on how to incorporate them successfully, particularly in graduate medical education (GME) in Emergency Medicine (EM). A national workgroup of academic EM faculty with expertise in these areas was assembled to identify priority research questions that address key knowledge gaps in the design, delivery, and outcomes of coaching and individualized learning within a CBME framework. Methods:Twelve members with diverse representation convened to conduct a three-round modified Delphi process to help identify high-impact scholarly questions that would inform a discipline-specific research agenda within the broader 2025 Society for Academic Emergency Medicine (SAEM) Consensus Conference on CBME. Results:The final 10 research questions identify a strategic direction to focus future scholarly initiatives relevant to EM and coaching in CBME. Four question categories were identified: coaching effectiveness and outcomes, coaching program design, faculty development and coaching competencies, and learner-centered factors. Implications:The consensus-building process revealed a pivotal period for EM's transition to CBME, with the need for more rigorous, evidence-driven understanding of coaching and individualized learning mechanisms, outcomes, and best practices to optimally prepare faculty and learners for successful implementation. The potential impact of this work not only affects individual learners but brings forth considerations for EM faculty, training programs, and national stakeholders to inform a supportive infrastructure and relevant resources to successfully actualize CBME in EM.

In order to optimize learner development, align rigorous assessment with individualized instruction, and ensure graduates can consistently provide trustworthy, excellent patient care, Emergency Medicine has joined a global medical education movement toward competency-based medical education (CBME). This shift focuses less on teaching specific content in a fixed period of time, and more on ensuring graduating physicians can be trusted to perform the essential activities required of their specialty. Emergency medicine collaborators have piloted implementing the five components of CBME: (1) An outcomes competency framework; (2) Developmental sequencing of competencies; (3) Individualized clinical experiences tailored to the competencies; (4) Competency-centered coaching; (5) Programmatic assessment with emphasis on workplace-based assessment. This work has included developing specialty-specific entrustable professional activities (EPAs), mapping EPAs to the ACGME Milestones, defining an ideal individualized learning plan, coaching pilots across multiple institutions, and implementing workplace-based assessment. Through these efforts across diverse residency programs, educators have experienced both the promise of CBME and the challenges to implementation and sustainability. In order to move the field forward, the 2025 Academic Emergency Medicine Consensus Conference aimed to develop a prioritized 10-year research agenda for CBME in Emergency Medicine graduate medical education to guide discovery over the next decade. This paper reports the process and results of the consensus proceedings, and outlines key research priorities for the following aspects of CBME specific to Emergency Medicine graduate medical education: (1) Coaching and individualized learning; (2) Faculty and Learner Development; (3) Assessment; and (4) Implementation and Change Management.

There is growing interest in coaching as a strategy to support competency-based medical education (CBME), individualized learning, development of Master Adaptive Learners, and precision education. Despite high enthusiasm, educators often struggle with how to begin developing an effective program. This educational blueprint describes two foundational decisions for launching a coaching program: defining program goals and selecting a theory of change with an aligned coaching model. We then examine contextual considerations, implementation challenges, and tradeoffs that influence these decisions. Grounding a program in explicit goals, educational theory and intentional model selection create a coherent foundation for subsequent design, implementation, and evaluation.

Background:It is essential that medical education (MedEd) fellows achieve desired outcomes prior to graduation. Despite the increase in postgraduate MedEd fellowships in emergency medicine (EM), there is no consistently applied competency framework. We sought to develop entrustable professional activities (EPAs) for EM MedEd fellows. Methods:From 2021 to 2022, we used a modified Delphi method to achieve consensus for EPAs. EM education experts generated an initial list of 173 EPAs after literature review. In each Delphi round, panelists were asked to make a binary choice of whether to include the EPA. We determined an inclusion threshold of 70% agreement a priori. After the first round, given the large number of EPAs meeting inclusion threshold, panelists were instructed to vote whether each EPA should be included in the "20 most important" EPAs for a MedEd fellowship. Modifications were made between rounds based on expert feedback. We calculated descriptive statistics. Results:Seventeen experts completed four Delphi rounds each with 100% response. After Round 1, 87 EPAs were eliminated and two were combined. Following Round 2, 46 EPAs were eliminated, seven were combined, and three were included in the final list. After the third round, one EPA was eliminated and 13 were included. After the fourth round, 11 EPAs were eliminated. The final list consisted of 16 EPAs in domains of career development, education theory and methods, research and scholarship, and educational program administration. Conclusions:We developed a list of 16 EPAs for EM MedEd fellowships, the first step in implementing competency-based MedEd.

Purpose Medical education should prepare learners for complex and evolving work, and should ideally include the Master Adaptive Learner (MAL) model-meta-learning skills for continuous self-regulated learning. This study aimed to measure obstetrics and gynecology (OB/GYN) residents' MAL attributes, assess associations with burnout and resilience, and explore learning task associations with MAL. Method OB/GYN residents were surveyed electronically at an in-training examination in January 2022. The survey included demographic information, the 2-item Maslach Burnout Inventory, the 2-item Connor-Davidson Resilience Scale, 4 MAL items (e.g., "I take every opportunity to learn new things"), and questions about training and learning experiences. Results Of 5,761 residents, 3,741 respondents (65%) were included. A total of 1,478 of 3,386 (39%) demonstrated burnout (responded positive for burnout on emotional exhaustion or depersonalization items). The mean (SD) Connor-Davidson Resilience Scale score was 6.4 (1.2) of a total possible score of 8. The mean (SD) MAL score was 16.3 (2.8) of a total possible score of 20. The MAL score was inversely associated with burnout, with lower MAL scores for residents with (mean [SD] MAL score, 16.5 [2.4]) vs without (mean [SD], 16.0 [2.3]) burnout (P < .001). Higher MAL scores were associated with higher resilience (R = 0.29, P < .001). Higher MAL scores were associated with the statement "I feel that I was well prepared for my first year of residency" (R = 0.19, P < .001) and a plan to complete subspecialty training after residency (mean [SD] of 16.6 [2.4] for "yes" and 16.2 [2.4] for "no," P < .001). Conclusions Residents who scored higher on MAL showed more resilience and less burnout. Whether less resilient, burned-out residents did not have the agency to achieve MAL status or whether MAL behaviors filled the resiliency reservoir and protected against burnout is not clear.

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.

On March 30, 1981, after President Reagan was shot in the chest by John Hinckley, he was taken to the hospital and required a chest tube. Rumor has it, a department chair stepped up to perform the procedure, hitting the intercostal artery in the process, necessitating a blood transfusion. As well-trained interns know, you place a chest tube above the rib; when you go below the rib, you may hit the intercostal artery. Although, this story may be urban legend, it resonates because it speaks to an important lesson—if you need a procedure, you want the person who does it the most frequently—the senior resident, junior attending, or specialized consultant. Most likely you do not want the department chair, associate dean, physician-scientist, part-time physician moving to retirement, or others with less clinical practice. Medical errors are common. Procedural complications are an important cause of adverse events, resulting in patient discomfort, longer hospital stays, and higher costs.1 These complications result in nearly 10% of hospital-wide adverse events; nearly half are considered preventable.2 For the past several years, our emergency medicine (EM) clinical practice has been about 20% of our time, less than 1 day a week. While we may be reluctant to admit it, the last lumbar puncture any of us performed was over a year ago, our last intubation was perhaps years ago, and a cricothyrotomy was in residency over 25 years ago. We practice in teaching hospitals, and have supervised these procedures, but have not recently performed them. While we believe that we are in equipoise, providing excellent patient care based on years of experience and balancing infrequent procedural performance, could we still do these procedures? Probably yes, maybe not perfectly, and at what risk to the patient? Yet, we still practice, and we accept the responsibility to provide optimal care for our patients. Moreover, our identity as competent emergency physicians is important and contributes to our professional credibility. Emergency physicians have a continuous responsibility to maintain competency. Yet medical care is rapidly changing; new procedures such as ultrasound-guided nerve blocks become standard of care. There are new diseases such as COVID and new treatments such as thrombectomy for stroke. Further, about half of patients' medications did not exist in medical school and may not know the interactions and side effects. In addition, there are numerous high-acuity low opportunity (HALO) procedures (e.g., thoracotomy, lateral canthotomy, and transvenous pacer)3 and HALO patient presentations (e.g., neonatal shock, thyroid storm). So how do EM physicians maintain their knowledge and competencies, much less extend these into emerging procedures, medications, diseases, and treatments? Maintenance of skills is important; crucial questions remain unanswered. What must EM physicians be competent in,4 for how long, and how? Where an expansive range of competencies are considered centrally important, it is clear not every practitioner maintains every competency. Achieving, assuring, and maintaining competency comes at a cost in time, effort, and perseverance for the individual and the system. Medical training cycles through periods of rapid learning with large gains in performance and expertise, especially during transitions to clerkship, residency, and practice (Figure 1).5, 6 Learning is accelerated by spaced repetition,7 interleaving,8 deliberate practice with feedback,9 and metacognitive techniques such as informed self-assessment10 and deep reflection.11 When formal training ceases, expert performance can eventually degrade. The rate of forgetting depends on a number of factors including the skill complexity, opportunities for practice, and system support.5, 6 Strong learning techniques can delay or lessen the forgetting curve, as does continued exposure through practice. Training for adaptive expertise mitigates some of forgetting effects. Educational designs emphasizing deep mechanistic understanding and an ability to cope with meaningful variation in patient care allows a physician to more ably approach problems for which they do not have a fully routinized approach.12 This acknowledges that a procedure that one provider has fully routinized, another provider might need to invoke their ability to innovate in the moment (i.e., adapt).6 However, while experience may provide better adaptive approaches, this can only take them so far, as our President Reagan chest tube story shows. In this perspective we raise questions of forgetting curves and the responsibility of managing procedural skills and clinical competency. Can the balance tip in a way that results in harm for patients? And what can we do to mitigate and protect? We propose four approaches. First, there is the external mandate for lifelong learning, continuing medical education credits for renewal of licensure, and the sticky problem of maintenance of certification and recertification examinations.13 While these are often unpopular and potentially ineffective, the underlying principle is solid. Physicians will forget what is not used, need to refresh core knowledge, and must learn the new knowledge and skills. Essential in this process is that physicians become master adaptive learners14, 15 who must recognize what they do not know, identify gaps, plan, and implement effective learning. Beyond mandatory CME and recertification, EM physicians have a responsibility to continue to learn for the benefit of their patients. The second approach invokes the responsibility of all physicians to maintain competency by retraining specifically for HALO and new procedures. Simulation is widely available but may not be used by practicing physicians and may not be considered part of a simulation centers' budget and mission. These opportunities allow physicians to refresh their procedural memory as well as develop familiarity with new equipment and methods. Some departments have faculty- specific voluntary procedural training or mandate training, such as annual procedural sedation certification.16, 17 There are national EM courses in domains such as airway, ultrasound, and trauma that facilitate learning. The third approach is that physicians can choose to limit their practice by working in settings where there is less exposure to the procedures or content in which they are no longer expert. EM physicians can work in lower acuity areas or locations with double coverage with reliance on colleagues as needed, locations with support of a procedural or ED/intensive care unit team, or adult hospitals (allow pediatric skills to decay). These options leverage alignment with systems-based approaches that maximize collective competence.18 The optimal solution is likely to differ between settings and EM providers.19 Finally, and perhaps most importantly, is the twin-mirror of self-assessment and reflection. Self-assessment can be poor, as shown by Dunning and Kruger's paper “Unskilled and unaware: How difficulties in recognizing one's own incompetence lead to inflated self-assessments.”20 Physicians may not realize or admit that they have lost competency. This threat to our professional identity—that of the competent physician—creates internal conflict. Emergency physicians must seek external metrics to provide informed self-assessment.10, 21 This requires us to understand how we ascend to expertise—the time, practice, and self-challenge that achieves peak performance. We must then also understand that when we cease to do the things that maintain that expertise, our experience can take us only so far, and performance may decline unless deliberate retraining steps are taken. In the face of forgetting curves, HALO procedures and cases, and expanding knowledge there is a responsibility of the medical profession to ensure that patients come first.22 We must place patient safety first and take this responsibility to self-assess and self-reflect—and importantly, to change—either ourselves or our practice if we recognize that the safety of patients is threatened by our decay in competence. More importantly, data-informed systems must be created to ensure that the patient safety/physician competency tension is not driven solely by the individual. Most of us know a colleague whose care we do not trust for patients or our family members or who we dread signing out to.23-25 The system must be intentional about identifying these providers and working to improve their care (Table 1). The chair in the opening story should not have been in the situation to place a chest tube if he had not performed them regularly. Health care systems need to develop proactive processes of continuous review of physician competency such as errors, near-miss, peer concerns, low volume of specific cases, safety events, complications, patient-reported outcomes, and patient and staff complaints. These metrics might launch a more extensive review of practice including peer assessments, direct observation, chart review, knowledge analysis, cognitive testing, procedural testing, and other methods of competency assessment.26 The challenge is that this may feel punitive27 and colleagues and systems are hesitant to trigger such a review out of collegial compassion and concern that there is not sufficient “evidence.” We need a proactive system that faces these issues directly with regular reviews of practice or mandatory competency assessments. Beyond surveillance, the health system must provide proactive, individualized, transparent training opportunities that mitigate skill attrition before it takes hold. Further, there must be recognition of the time and resources it takes to retain skills and this should be supported by health systems. Our responsibility is to maintain competency. The locus of responsibility for ensuring competency must be shared between the individual and the health system to provide safe and effective care for patients. The authors declare no conflicts of interest. Robin Hemphill is an employee of the Veteran's Health Administration (VHA). These views are her own and do not represent the views of the VHA.

INTRODUCTION:Residency didactic conferences transitioned to a virtual format during the COVID-19 pandemic. This format creates questions about effective educational practices, which depend on learner engagement. In this study we sought to characterize the competitive demands for learner attention during virtual didactics and to pilot methodology for future studies.METHODS:This was a prospective, observational, cohort study of attendees at virtual didactics from a single emergency medicine residency, which employed a self-report strategy informed by validated classroom assessments of student engagement. We deployed an online, two-question survey polling across six conference days using random signaled sampling. Participants reported all activities during the preceding five minutes.RESULTS:There were 1303 responses over 40 survey deployments across six nonadjacent days. Respondents were residents (63.4%); faculty (27.5%); fellows (2.3%); students (2%); and others (4.8%). Across all responses, about 85% indicated engagement in the virtual conference within the last five minutes of the polls. The average number of activities engaged in was 2.0 (standard deviation = 1.1). Additional activities included education-related (34.2%), work-related (21.1%), social (18.8%), personal (14.6%), self-care (13.4%), and entertainment (4.4%).CONCLUSION:Learners engage in a variety of activities during virtual didactics. Engagement appears to fluctuate temporally, which may inform teaching strategies. This information may also provide unique instructor feedback. This pilot study demonstrates methodology for future studies of conference engagement and learning outcomes.

Medical students experience anxiety when learning the pelvic, breast and male genitourinary exam (also known as sensitive physical exams). Reflection can help students process emotionally challenging learning experiences and help give those experiences meaning. We describe the development of a reflection module to enhance reflection during sensitive exam instruction. We developed this module following Kern's Six Step Method for curriculum development, including a targeted needs assessment. Informed by educational reflection theory, the module addressed all elements of reflection. The module was optional, asynchronous and administered online, requiring minimal administrative support. Prior to sensitive exam instruction, participants identified goals and values and named emotions. Following exam instruction, participants again named their emotions and then self-evaluated whether they had met their goals and upheld their values. Participants found the module to be a useful modality to reflect. Most notably, they identified the naming of emotions, goals and values clarification and the opportunity to reflect both prior to and after an educational experience as helpful. Younger students found the module particularly helpful. An online, low-resource, asynchronous reflection module is feasible and can be a way for students to reflect on challenging learning experiences. In addition to using with sensitive exam instruction, the module can be applied to activities such as anatomic dissection, ethics workshops or clinical learning.

BACKGROUND:Coaching supports academic goals, professional development and wellbeing in medical education. Scant literature exists on training and assessing coaches and evaluating coaching programs. To begin filling this gap, we created a set of coach competencies for medical education using a modified Delphi approach.METHODS:An expert team assembled, comprised of seven experts in the field of coaching. A modified Delphi approach was utilized to develop competencies.RESULTS:Fifteen competencies in five domains resulted: coaching process and structure, relational skills, coaching skills, coaching theories and models, and coach development.CONCLUSION:These competencies delineate essential features of a coach in medical education. Next steps include creating faculty development and assessment tools for coaching.

It can be difficult to carve out dedicated time to teach in the busy environment of the Emergency Department. With some intention, you can find educational opportunities in every shift. Here we highlight some of those opportunities, with careful attention to those without special equipment or preparation required. These can be used to teach less traditional practice points such as interprofessional communication as well as clinical pearls. Select the moments that make the most sense for you, your trainees, and your shift.

Introduction: Forming effective networks is important for personal productivity and career development. Although critical for success, these networks are not well understood. The objective of this study was to usze a social network analysis tool to demonstrate the growth of institutional publication networks for education researchers and show how a single institution has expanded its publication network over time. Methods: Publications from a single institution's medical education research group (MERG) were pulled since its inception in 2010 to 2019 using Web of Science to collect publication information. Using VOSViewer software, we formed and plotted a network sociogram comparing the first five years to the most recent 4.25 years to compare the institutions of authors from peer reviewed manuscripts published by this group. Results: We found 104 peer-reviewed research articles, editorials, abstracts, and reviews for the MERG authors between 2010 and 2019 involving 134 unique institutions. During 2010-2014, there were 26 publications involving 56 institutions. From 2015-2019, there were 78 publications involving 116 unique institutions. Conclusion: This brief report correlates successful research productivity in medical education with the presence of increased inter-institutional collaborations as demonstrated by network sociograms. Programs to intentionally expand collaborative networks may prove to be an important element of facilitating successful careers in medical education scholarship.

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.

BACKGROUND:Patient safety has become an important and required topic in medical education. A needs assessment showed that pediatric emergency medicine program directors were interested in a common pediatric emergency-specific safety curriculum.OBJECTIVE:The objective of this study was to describe the development and performance of a web-based patient safety curriculum in pediatric emergency medicine.METHODS:A web-based curriculum was created by the Committee on Quality Transformation of the Section of Emergency Medicine for the American Academy of Pediatrics. The curriculum consisted of emergency-specific safety topic didactic sessions with a pretest and posttest assessment. Vignette-based scenarios were also included and were discussed locally by the program directors.RESULTS:Fifty-two percent (37/71) of US Pediatric Emergency Medicine fellowship programs enrolled their fellows in the patient safety curriculum. Overall, 183 Pediatric Emergency Medicine fellows participated in the curriculum. Only 22% (40/183) of fellow participants completed the entire curriculum. The curriculum showed significant improved safety knowledge based upon the pretest and posttest results. Sixty-five percent of responders thought more about safety topics after the curriculum was completed, and 85% witnessed a safety event in the past month, whereas only 48% reported them.CONCLUSIONS:An online centralized curriculum is an effective platform for teaching content in quality and safety to a national group of physicians. Local oversight by program directors may improve compliance with curriculum completion.

With 30,000,000 emergency department (ED) visits annually, children account for nearly one-fourth of all ED visits in the United States. Despite these statistics, EDs across the country remain underprepared to care for pediatric patients.1, 2 Based on published data, only 45% of EDs report having a pediatric quality improvement plan in place, one-third of hospitals do not weigh children in kilograms, less than half have disaster plans in place for pediatric patients, and more than 15% are missing critical pediatric emergency equipment.1 These deficiencies may be due in part to the fact that 80% of children are cared for in non–children's hospital EDs of which 39% nationally see fewer than five children per day and 69% see fewer than 14 children per day.1 Pediatric readiness has improved over the past 10 years since the 2006 Institute of Medicine call for improved pediatric emergency care; however, it is clear that there are still improvements to be made.3 This paper will address current challenges, novel opportunities for educational innovations, and next steps in the maturity of emergency care for children in all practice settings. Advancing pediatric emergency medicine (PEM) within emergency medicine (EM) is challenging at all levels, from undergraduate medical education into clinical practice. At the undergraduate level, medical students entering EM residencies often have only 8 to 10 weeks of total pediatric exposure. The mechanism for this training is also varied with “all-comers” EDs, stand-alone pediatric EDs, and pediatric EDs embedded within the general ED, all serving as settings to deliver educational and practice content. This is further exacerbated into residency where only 16% of EM training time is devoted to pediatrics.4 The limited residency time that is devoted to PEM can lead to a superficial understanding of pediatrics and may preclude trainees from experiencing the seasonal variability of pediatric illnesses. Most EM residents in the United States train in one of nearly 200 tertiary pediatric centers where the fraction of critically ill patients is low, even in high-volume centers; ultimately only 1% to 5% of pediatric visits require resuscitation.5 The limited number of learning opportunities with critically ill pediatric patients leaves learners vying for hands on experience.6 Cloutier et al.4 in 2010 presented a set of “Best Practices for Pediatric Emergency Medicine Training in EM Residency,” outlining educational challenges facing modern EM programs and proposed methods to maximize limited resources in both time and patient exposure. While some of the information cited was based on survey data collected in the mid- to late-90s, many of the challenges still persist today. At the attending level there are several barriers to dissemination and adoption of information. Emergency physicians (EPs) often mistakenly assume there are gaps in their skills to manage the critically ill child when, in fact, they possess a high level of critical care resuscitation competency. The greatest area of need is, paradoxically, how to risk stratify the relatively well-appearing ambulatory pediatric patient. EPs in general are capable of resuscitating the “crashing” pediatric patient yet may fail to recognize the compensated ill child, and specifically infants who account for a larger proportion of children requiring resuscitation, and thereby miss the opportunity to divert that child from a potentially fatal outcome. Numerous studies have compared the behaviors of PEM trained to EM trained (non-PEM) practitioners and have noted significantly higher diagnostic testing rates among non-PEM trained physicians.7 While such testing may assuage the clinical uncertainty derived from inexperience, it does little to refine medical decision making or optimize patient care and resource utilization. Viewed broadly, the best use of educational time for EPs would focus on high-frequency, high-impact events: evidence-based guidelines for antibiotic stewardship, the appropriate use of diagnostic imaging, pediatric pain management/procedural sedation, and clinical pathways for common pediatric visits such as bronchiolitis or appendicitis. These are skill sets EPs would be likely to use in a wide variety of clinical environments. Attention to the critical child remains a priority—however, it is no longer a sufficient core for EPs. Additionally, retaining core pediatric emergency care skills allows for greater practice flexibility over a full career time frame. To date there are over 2,000 PEM-certified physicians in the United States. Only 294 of these providers are certified through the American Board of Emergency Medicine. The results of this imbalance are clear in two key ways. First, PEM clinical progress has grown rapidly over the past 20 years, and nearly all of it emanates from pediatrics rather than EM. Second, the PEM research consortia, such as Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC) and Pediatric Emergency Care Applied Research Network (PECARN), are overwhelmingly administered and run through pediatrics with the vast majority of meaningful findings presented at meetings that are not typically attended by EM-trained providers. The quality and quantity of research, especially by larger research collaborations such as the PEM-CRC and PECARN, have contributed to PEM's development of a unique identity that seems a world apart from general EM. What remains is an insufficient interface between pediatrics and EM that limits the proper diffusion of PEM knowledge across the broadest possible scope of clinical environments. Indeed, the vehicles such as social media Free Open Access Medical Education (i.e., #FOAMed and #FOAMped) may serve to assist in bridging the knowledge gap between pediatrics and EM and offer improved yield for the dissemination of critical PEM information.8 Nonetheless, greater engagement with EM to incorporate advances in PEM is a vital step to help bridge key gaps between these two intertwined specialties. Increased use of technology to diffuse innovation such as FOAMed or simulation curricula for EM physicians is an effective instructional methodology that can provide prescribed exposure to pediatrics for students, residents, and attendings in pediatrics. Rapid integration of simulation into PEM fellowships and EM residency programs may provide powerful opportunities for diffusion of the new workforce with subsequent expansion to established providers in novel venues. There exists an increasing gap between what we know (the creation of knowledge through basic and clinical research) and what we do (the application of systems and structures of knowledge systems to the care of individual patients and at the level of population health). The process of knowledge translation is meant to span that gap, identifying clinical problems, informing basic science and clinical research, implementing the findings of scientific inquiry at the bedside, and evaluating clinical outcomes. Various terms have been coined to describe the process by which problems stimulate innovations and inform practice: knowledge transfer, knowledge exchange, implementation, dissemination, diffusion, and knowledge translation. This latter term has gained favor in recent years,, and has been adopted by international research and clinical bodies. The Canadian Institutes of Healthcare Research (CIHR) defines knowledge translation as “a dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products, and strengthen the health care system.”9 There is not a fully validated theoretical framework on which best practices in knowledge translation can be based.10 To address this gap in understanding, CIHR has funded a multidisciplinary Team in Pediatric Emergency Medicine and Knowledge Translation (TREKK, trekk.ca) whose goal is to improve health outcomes for children in both pediatric and general hospital EDs.11 Their work is based on an “Iterative Figure of Eight” conceptual framework (Figure 1), which includes a clinical research component and a knowledge translation component, but which runs the gamut from epidemiology to basic clinical knowledge to dissemination and diffusion to real-world evaluation of clinical and public health outcomes.12 Another conceptual framework for knowledge translation, the “Knowledge-to-Action” (KTA) cycle, emphasized the importance of the broad range of stakeholder involved in knowledge translation—including, but not limited to, researchers and policy-makers.13 Each conceptual framework emphasizes that the process is not unidirectional. Information and innovation cannot be “pushed” into practice if their application is not relevant and useful. Likewise, clinicians cannot simply “pull” ready-made solutions from basic researchers. The process of knowledge translation must be multidirectional or cyclical, involving development, uptake, and dissemination. Innovators must make their work available for dissemination, while clinicians and policy-makers must recognize opportunities to evaluate current practices in light of new information, incorporating innovation into practice.14 The cyclical nature of this process is meant to ensure that knowledge generated is relevant, useful, and applicable and that its implementation into practice leads to improved health outcomes and is intuitive to the practitioner with direct application to the front-line clinician.15, 16 The traditional process of dissemination and diffusion of novel or innovative understanding or practices via publication in peer-reviewed journals and spread through slowly evolving practice patterns is both ponderous and unpredictable. Recent advancements have streamlined this process, harnessing the power of social and other networks to speed the dissemination of knowledge and practice. Social media as a paradigm for rapid dissemination of innovation has been proposed as one solution to the knowledge-practice gap.17 Although risks of rapid dissemination prior to rigorous peer review are real, the use of free, open-access distribution may still offer a critical route by which innovative findings can be made widely available. Several traditional print journals have partnered in this process, although outcomes in terms of uptake into practice and clinical outcomes are largely unknown at this point.18-21 As noted above, national meeting attendance as a vehicle for best-practice dissemination is challenging for PEM. The temporal proximity of the Pediatric Academic Societies and Society of Academic Emergency Medicine annual scientific assemblies in the spring and the American Academy of Pediatrics and American College of Emergency Physicians meetings in the fall illustrates this barrier. Pragmatic relationship building between shielded communities of practitioners and innovators, even in the advent of technology, must remain as part of the solution. In the United States, state and local government regulations may exist to mandate ED pediatric standards. For example, in the state of New Jersey, all EDs are required to have a designated pediatric liaison physician and a designated pediatric liaison nurse, in addition to meeting other pediatric readiness standards. This is supplemented by federally funded initiatives such as the Emergency Medical Services for Children (EMSC), which has various ED pediatric readiness resources on its website and maintain the ED-Approved for Pediatrics (EDAP) certification program in some states. The pediatrics readiness score, a multiorganizational collaborative with AAP, ENA, and ACEP, is an example of a leadership collaborative that allows for accessible pediatric emergency care practice in any setting. In certain countries, government bodies may take the lead in setting the standard for care. An example is the National Institute for Health and Care Excellence (NICE) in the United Kingdom, which examines the prevailing literature to determine the best practice in various settings including pediatric patients treated in EDs. In the United States, clinical practice guidelines are generally produced by specialty organizations such as the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP). Examples of CPGs relevant to pediatric emergency care include bronchiolitis guidelines, febrile seizure guidelines, and otitis media guidelines.22-24 ACEP has also partnered with the American Board of Internal Medicine Foundation in developing Choosing Wisely items, aimed to minimize unnecessary testing in the ED. The AAP/ACEP Advanced Pediatric Life Support (APLS) course was created to enhance pediatric skills in emergency care providers and has been a popular offering since its inception. Finally, broad publication of pediatric hospital clinical pathways and guidelines and standardized order sets and utilization of the electronic medical record to streamline care is an ongoing movement with the goal of decreasing practice variation and increasing provider access to evidence-based standards of care. Recommendations from landmark clinical trials have at times been widely adopted at the national level. A great example is the Pediatric Emergency Care Applied Research Network (PECARN) head injury imaging recommendations, which resulted from a multi-institutional, rigorously conducted, large-sample-size study.25 In addition to sound, easy-to-remember criteria, coordinated dissemination of the study findings also likely contributed to its widespread acceptance. Regrettably, this is more the exception than the rule for dissemination of PEM innovations. Best practice consistent with current scientific knowledge can also be implemented at the local ED level. Often a well-planned, multiprong, multidisciplinary approach with a dedicated task force made up of various stakeholders is necessary for its success. Examples of ED process change leading to improved pediatric outcomes include those dealing with sepsis, appendicitis, sickle cell disease, asthma, and bronchiolitis.26-31 Although most of the published literature on best-practice examples took place in pediatric EDs, effective integration of best practice in general EDs have also been reported.32, 33 Furthermore, meaningful practice change in community EDs is likely underreported because of the nonacademic nature of many of their staff. Suggested best practice to address these issues is supporting a physician and nursing coordinator as pediatric champion for every ED. Another underreported means of diffusion of innovation is community provider outreach education efforts by those familiar with latest development in the field, e.g., PEM specialists. This can take the form of lecture, interactive workshop, webinars, online discussion groups, or even department-wide global educational efforts. The obvious shortfall of this method is that it can only reached a limited number of audiences at a time. Mechanisms for knowledge translation, communication of standards, and new developments in PEM are currently haphazard. These loosely converge through the myriad of professional societies and healthcare organizations that oversee the emergency care of children. In an era of rapid information delivery, cost imperatives, and consumer advocacy, the more static model for diffusion of innovation is ripe to transform into a dynamic one. Moreover, each innovation must offer a clear advantage over existing practices or technology: “Innovation means change, whether it is incremental or on the ‘big bang’ level. Regardless of the scope of the innovation, it must be real in the sense that it results in a true improvement in quality. A true quality improvement follows the discovery of a market need for something that fits with the organization's purpose.34 True innovation ultimately facilitates the engagement of stakeholders and propels the knowledge-to-action cycle forward.35 Each viable innovation must have at its core a simplicity that disrupts other practices or technology and a value that cannot be ignored.36 Viewed broadly, the next steps for consistently translating innovations in PEM into action entail both reliable sources to identify true innovation and a network that sustains a dynamic diffusion of that innovation to all of the providers who care for children. Novel research developments and evidence-based practices continue to emerge in PEM. Much of this progress can be readily adopted at pediatric tertiary care centers, with a relatively slower integration through the many other centers and providers that care for pediatric patients. The reasons for this differential pace are clearly multifactorial. A key issue is cost and feasibility for the end-user. What is novel and interesting may not be innovative enough to justify cost and thereby transform care on a broad scale. National networks are vital to the dissemination of information that can close “knowledge gaps and share evidence and best practices.”37 The next step is to reliably identify each innovation—sift it out from other developments—and provide a consistent and clear message on its value to end-users. Pediatric tertiary care centers, professional societies, and other agencies that focus on PEM share the task to bring innovation to the fore and promote its dissemination through local, national, and global networks. Rogers ‘s37 diffusion of innovation theory posited a normal distribution of adoption over time. The “innovators” and “early adopters” embrace the change of an innovation, while those in the “early majority” and “late majority” weigh in on feasibility issues and local obstacles, which ultimately delays their process of change. Finally, the “traditionalists” or “laggers” refrain from change on the assumption that it represents a loss until eventually proven otherwise.38 Indeed the spectrum of innovation diffusion is as diverse as Rogers described, yet the process of change is now far more dynamic. In a dynamic diffusion of innovation process, “ideas are evolving during the course of adoption, and innovation researchers are already well aware that people actively modify an adopted idea whenever it is possible and necessary … it is the rule rather than the exception that every modified innovation may well compete with all its predecessors, so the picture becomes more colorful than the dichotomy of a new idea versus an old one.”37 Coordinated initiatives and networks that are possible in our modern world are key to promoting and sustaining widespread practice change.34 Broader channels for communication and coordination between professional societies, healthcare organizations, and government entities are key to a robust and dynamic diffusion of innovative ideas, practices, and technologies to benefit children nationally and worldwide. In a new era where diffusion of innovation evolves as a dynamic process, “knowledge-to-practice gaps” can be closed or even eliminated to sustainably improve healthcare outcomes for children. “Carrot-versus-stick” mentality must be carefully balanced to ensure broad adoption and implementation. The marching orders are clear for EPs in all practice settings: collaboration among providers from all training pathways must be solidified in educational forums, practice guidelines, FOAMed forums, and leadership development. The practice of PEM is a true team sport across the country and worldwide, with providers of all backgrounds required to provide appropriate and excellent care for 30,000,000 children annually. EM providers shoulder the largest share of initial diagnosis and management of children, making the diffusion process imperative for our specialty. Best-practice models for this exist and coordination among lifelong learning entities must focus on this specialty content knowledge moving forward.

The pediatric emergency medicine (PEM) environment is well suited for simulation-based activities, be they educational interventions for PEM learners, evaluations of the interface between health providers and the environment that they work in, or research investigations using simulation as a tool to answer specific clinical questions. As such, PEM has been among the leaders in the integration of this modality for clinical training. Traditionally, simulation has been used extensively for the dissemination of clinical training in the areas of clinical knowledge and its application, and the clinical, technical, and teamwork skills involved in PEM care. Increasingly, simulation is being used in novel applications, including breaking bad news, disclosure of error, family-centered care, quality and patient safety education, and system-level integration. The future will look to further identify, measure, and inform the integration of simulation with new and innovative adjuncts in the clinical environment, as well as to determine the optimal timing and use of simulation-based education to enhance the quality of care delivered to patients by the interprofessional and multidisciplinary team.