Case Presentation: We present a case of a 79-year-old male with gastric outlet obstruction resulting from a stomach herniation through a large left inguinal hernia. Discussion: Stomach-containing inguinal hernias are a rare cause of gastric outlet obstruction. Treatment options range from conservative to surgical management. Once identified with imaging, prompt treatment should be initiated to prevent incarceration, strangulation, and gastric necrosis.

residency programs should consider offering electives in the medical humanities to improve empathy, communication, observation, and decrease burnout in their residents.

BACKGROUND:Effective feedback is the cornerstone of competency-based education. The emergency department (ED) is a unique learning and feedback environment. Developing our understanding of emergency medicine (EM) residents' experiences around feedback will improve resident training and inform EM faculty development programs.OBJECTIVE:This qualitative study explores the feedback culture and practices in EM and resident's experiences and attitudes toward feedback in this specific training environment.METHODS:At a large categorical EM program, 15 residents voluntarily participated in semistructured interviews regarding feedback. These individual interviews were performed by a nonphysician investigator and transcripts underwent an inductive multistep coding process. Transcripts were analyzed to identify common factors influencing feedback and then comparisons were made between residents to explore the interconnectedness of identified factors and further categorize consistent themes.RESULTS:Factors inherent to the ED environment make the delivery of effective feedback challenging. Residents also revealed that feedback-seeking/-avoidant behavior and receptivity to feedback are multifactorial. Residents actively seek feedback when they feel that they performed well but tend to avoid feedback interactions when they expect constructive feedback. Finally, residents filter feedback based on attending personality and perceived practice style as well as their own desired practice style.CONCLUSIONS:It is important for program leaders to understand their residents' experiences with feedback and engage both faculty and residents in conversations around feedback delivery and receptivity. An improved understanding of these experiences might also reveal barriers to performance assessment and guide efforts to improve the accuracy and reliability of resident evaluations.

Introduction: Care of pediatric cancer patients is increasingly being provided by physicians in community settings, including general emergency departments. Guidelines based on current evidence have standardized the care of children undergoing chemotherapy or hematopoietic stem cell transplantation (HSCT) presenting with fever and neutropenia ( EN). Objective: This narrative review evaluates the management of pediatric patients with cancer and neutropenic fever and provides comparison with the care of the adult with neutropenic fever in the emergency department. Discussion: When children with cancer and FN first present for care, stratification of risk is based on a thorough history and physical examination, baseline laboratory and radiologic studies and the clinical condition of the patient, much like that for the adult patient. Prompt evaluation and initiation of intravenous broad-spectrum antibiotics after cultures are drawn but before other studies are resulted is critically important and may represent a practice difference for some emergency physicians when compared with standardized adult care. Unlike adults, all high-risk and most low-risk children with FN undergoing chemotherapy require admission for parenteral antibiotics and monitoring. Oral antibiotic therapy with close, structured outpatient monitoring may be considered only for certain low-risk patients at pediatric centers equipped to pursue this treatment strategy. Conclusions: Although there are many similarities between the emergency approach to FN in children and adults with cancer, there are differences that every emergency physician should know. This review provides strategies to optimize the care of FN in children with cancer in all emergency practice settings. (C) 2021 Elsevier Inc. All rights reserved.

Purpose The diagnostic yield of computed tomographic pulmonary angiography (CTPA) for pulmonary embolism varies in the literature, and very little data is available regarding community-based systems. This study evaluates the yield of CTPA for pulmonary embolism across a variety of patient care settings in a community-based healthcare system, providing relevant benchmarks for potential quality improvement efforts. Methods This retrospective study included data collected from three sites within a single community-based healthcare system, including a tertiary care level 1 trauma center, an urban community hospital, and a suburban free-standing emergency department. CTPAs were identified by Current Procedural Terminology codes, and diagnoses of pulmonary embolism were identified via International Classification of Diseases codes. A total of 7850 CTPA studies met criteria for inclusion between January 1, 2012, and October 8, 2014. Results Pulmonary embolism was found in 884 (11.3%) of the studies performed. Outpatients had a lower yield of pulmonary embolism (3.8%, p < 0.001) compared with inpatients (14.1%) and emergency department patients (10.7%, p < 0.001). Patients with diagnoses of deep vein thrombosis or neoplasm had increased incidence of pulmonary embolism when compared with patients without these diagnoses ( p < 0.001 for both). Conclusion The overall yield of CTPA for pulmonary embolism in this community-based system was similar to that at academic centers. The yield was significantly lower in the outpatient setting compared with studies originating in the emergency department or inpatient setting.

Background: Use of an age-adjusted D-dimer for the evaluation of acute pulmonary embolus (PE) has been prospectively validated in the literature and has become a practice recommendation from major medical societies. Most research on this subject involves the most common D-dimer assays reporting in Fibrinogen Equivalent Units (FEU) with a non-age-adjusted manufacturer-recommended cutoff of 500 ng/ml FEU. Limited research to date has evaluated age-adjustment in assays that report in D-Dimer Units (D-DU), which use a manufacturer-recommended cutoff of 230 ng/ml D-DU. Despite scant evidence, an age-adjusted formula using D-DU has been recently endorsed by the American College of Emergency Physicians (ACEP). This formula seems arbitrary in its derivation and unnecessarily deviates from existing thresholds, thus prompting the creation of our novel-age adjustment formula. The goal of this study was to retrospectively evaluate the test characteristics of our novel age-adjusted D-dimer formula using the D-DU assay in comparison to existing traditional and age-adjusted D-dimer thresholds for the evaluation of acute PE in the ED. Methods: This was a retrospective chart review at an academic quaternary health system with three EDs and 195,000 combined annual ED visits. Only patients with D-dimer testing and CT PE protocol (CTPE) imaging were included. Admission and discharge diagnosis codes were used to identify acute PE. Outcome measures were sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of an unadjusted traditional threshold (230) compared with both novel and ACEP-endorsed age adjusted thresholds, (Age x 5) - 20 and Age x 5 if >50, respectively. Estimates with their exact 95% threshold were performed. Results: 4846 adult patients were evaluated from January 2012 to July 2017. Group characteristics include a mean age of 52 and a frequency of acute PE diagnosis by CTPE of 8.25%. Traditional D-dimer cutoff demonstrated a sensitivity of 99.8% (95% CI 98.6-100), specificity of 16.7% (95% CI 15.6-17.8) and NPV of 99.9% (95% CI 99.3-100). Our novel age-adjusted D-dimer thresholds had a sensitivity of 97.0% (95% CI 94.8-98.4), specificity of 27.9% (95% CI 26.6-29.2) and NPV of 99.0% (95% CI 98.3-99.5) with the ACEP-endorsed formula demonstrating similar test characteristics. Conclusion: Use of an age-adjusted D-dimer on appropriately selected patients being evaluated for acute PE in the ED with a D-DU assay increases specificity while maintaining a high sensitivity and NPV. Both our novel formula and the ACEP-endorsed age-adjusted formula performed well, with our novel formula showing a trend towards improved testing characteristics. (C) 2018 Elsevier Inc. All rights reserved.

Introduction Educators struggle to develop a journal club format that promotes active participation from all levels of trainees. The explosion of social media compels residencies to incorporate the evaluation and application of these resources into evidence-based practice. We sought to design an innovative “flipped journal club” to achieve greater effectiveness in meeting goals and objectives among residents and faculty. Methods Each journal club is focused on a specific clinical question based on a landmark article, a background article, and a podcast or blog post. With the “flipped” model, residents are assigned to prepare an in-depth discussion of one of these works based on their level of training. At journal club, trainees break into small groups and discuss their assigned readings with faculty facilitation. Following the small-group discussions, all participants convene to summarize key points. In redesigning our journal club, we sought to achieve specific educational outcomes, and improve participant engagement and overall impressions. Results Sixty-one residents at our emergency medicine program participated in the flipped journal club during the 2015–2016 academic year, with supervision by core faculty. Program evaluation for the flipped journal club was performed using an anonymous survey, with response rates of 70% and 56% for residents and faculty, respectively. Overall, 95% of resident respondents and 100% of faculty respondents preferred the flipped format. Conclusion The “flipped journal club” hinges upon well-selected articles, incorporation of social media, and small-group discussions. This format engages all residents, holds learners accountable, and encourages greater participation among residents and faculty.

Introduction: Goal setting is used in education to promote learning and performance. Debriefing after clinical scenario-based simulation is a well-established practice that provides learners a defined structure to review and improve performance. Our objective was to integrate formal learning goal generation, using the SMART framework (Specific, Measurable, Attainable, Realistic, and Time-bound), into standard debriefing processes (i.e., "SMART Goal Enhanced Debriefing") and subsequently measure the impact on the development of learning goals and execution of educational actions. Methods: This was a prospective multicenter randomized controlled study of 80 emergency medicine residents at three academic hospitals comparing the effectiveness of SMART Goal Enhanced Debriefing to a standard debriefing. Residents were block randomized on a rolling basis following a simulation case. SMART Goal Enhanced Debriefing included five minutes of formal instruction on the development of SMART learning goals during the summary/application phase of the debrief. Outcome measures included the number of recalled learning goals, self-reported executed educational actions. and quality of each learning goal and educational action after a two-week follow-up period. Results: The mean number of reported learning goals was similar in the standard debriefing group (mean 2.05 goals, SD 1.13, n=37 residents), and in the SMART Goal Enhanced Debriefing group (mean 1.93, SD 0.96, n=43), with no difference in learning goal quality. Residents receiving SMART Goal Enhanced Debriefing completed more educational actions on average (Control group actions completed 0.97 (SD 0.87), SMART debrief group 1.44 (SD 1.03) p=0.03). Conclusion: The number and quality of learning goals reported by residents was not improved as a result of SMART Goal Enhanced Debriefing. Residents did, however, execute more educational actions, which is consistent with the overarching intent of any educational intervention.

While emergency medicine (EM) faculty are generally the most appropriate teachers for EM residents, there are components of the EM curriculum that benefit from specialist input. However, many times non-EM specialists have little appreciation for the challenges inherent in EM practice. In addition, presentations by specialists may address topics that are relevant to their practice, but outside the scope of EM. Residency leaders can feel challenged in giving constructive feedback to faculty speakers from other departments. In our setting, as in most, outside specialists are contributing their time without contractual requirements or personal benefit.We developed the Consultant Chat, a novel didactic format for specialists who are frequently consulted by the emergency department (ED). Expert consultants are selected by the senior EM residents and invited to come have a “chat” with our residents for 1 hour during the weekly EM conference time. These specialists do not prepare a presentation; they simply answer questions from the audience and share their experience. Residents are instructed to come prepared with questions that are specific, case based, and pragmatic. Common questions include: How would you expect us to approach “X” presentation? Under what circumstances would you want to be called in the middle of the night? What is your biggest “gripe” about cases that you have seen from the ED? Take-home points are recorded by an assigned resident and distributed to all EM residents and faculty as a summary document of “clinical pearls.”The Consultant Chat has greatly fostered collaboration with our specialists from other departments. In the last 18 months, we have held over a dozen Consultant Chat sessions with specialists from orthopedic surgery, plastic surgery, otolaryngology, neurology, gastroenterology, urology, and oral/maxillofacial surgery. The consultants feel honored to be selected by the residents, there is minimal time commitment on their part, and the informal atmosphere is engaging for all parties. They are motivated to share their knowledge with residents that will have a positive impact on patient care and may prevent unnecessary phone calls from the ED. The residents drive the discussion to ensure their education needs are met, and this self-directed learning style allows them to derive maximal value from the sessions. In addition, our faculty enjoy attending these sessions, as they can contribute their experience and management viewpoints, and engage their specialist colleagues in a friendly, educational atmosphere.Our EM residents have expressed greater comfort and confidence in knowing when to consult specialists from the ED, and anecdotal evidence suggests that communication with outside departments has improved. Our specialists have gained a greater understanding of the limited resources and challenges of the ED, as these are openly discussed during the sessions. Our curriculum committee, composed of residency leadership and selected faculty and residents, has evaluated the positive feedback from these sessions and worked to make them a regular component of the EM curriculum. Our novel didactic format has proven successful in our EM program; it could also be successfully adapted to any “generalist” training program, such as family medicine, internal medicine, pediatrics, or general surgery. The Consultant Chat represents a didactic model that develops not only the medical knowledge of our trainees, but also essential skills in communication, professionalism, and collaboration.

Obstacle, adventure and endurance competitions in challenging or remote settings are increasing in popularity. A literature search indicates a dearth of evidence-based research on the organisation of medical care for wilderness competitions. The organisation of medical care for each event is best tailored to specific race components, participant characteristics, geography, risk assessments, legal requirements, and the availability of both local and outside resources. Considering the health risks and logistical complexities inherent in these events, there is a compelling need for guiding principles that bridge the fields of wilderness medicine and sports medicine in providing a framework for the organisation of medical care delivery during wilderness and remote obstacle, adventure and endurance competitions. This narrative review, authored by experts in wilderness and operational medicine, provides such a framework. The primary goal is to assist organisers and medical providers in planning for sporting events in which participants are in situations or locations that exceed the capacity of local emergency medical services resources.

Transition from a templated paper documentation system to an electronic medical record (EMR) for emergency departments (EDs) has been associated with initial, and persistent, decreases in physician productivity metrics. While most studies to date have assessed the impact on attending physician metrics, our study sought to evaluate the change in resident productivity metrics associated with the implementation of an EMR.

Determine whether the implementation of a statewide opiate prescribing policy is associated with a decrease in the number of prescriptions for opiates for discharged emergency department patients. Retrospective review of opiate prescriptions written by medical professionals comparing a 4 month period before and after the implementation of an opiate prescribing policy. An independent samples t-test was conducted to examine the differences in the mean number of total prescriptions per patient per day, opiate prescriptions per patient per day, total number of visits per day, and total number of opiate prescriptions per day. In the four-month period prior to implementation of the policy, there was an average of 0.196 (SD=0.005) opiate prescriptions per patient per day. This decreased to 0.188 (SD=0.015) opiate prescriptions per patient per day in the four-month period after the policy. The difference was not statistically significant (mean difference = 0.009; 95% CI: -0.014, 0.03; p = 0.35). Before the policy, there was also an average of 0.84 (SD=0.015) prescriptions/day and, after the policy, this decreased to 0.79 (SD=0.04) prescriptions/day (mean difference = 0.046; 95% CI:-0.018, 0.11; p = 0.10). The average number of total visits per day decreased over this time period (483 (SD=4.1) vs, 463 (SD=11.2); mean difference=20.2; 95% CI: 3.2, 36.8; p =0.03) as did the total number of opiate prescriptions per day (405 (SD=4.5) vs 367 (SD=27.9); mean difference=37.7; 95%CI: -4.9, 82.7; p = 0.07). Controlling for daily emergency department volume and total prescriptions, the proportion of prescriptions written for opiates remained relatively unchanged with the implementation of a statewide opiate prescribing policy. This may indicate that the effect of prescribing policies cannot be accurately measured using number of prescriptions written. Alternatively, quantity of pills per prescription may be a more appropriate measure of such a policy’s success.

BACKGROUND:Effective communication is critical for health care professionals, particularly in the Emergency Department (ED). However, currently, there is no standardized consultation model that is consistently practiced by physicians or used for training medical graduates. Recently, the 5Cs of Consultation model (Contact, Communicate, Core Question, Collaborate, and Close the Loop) has been studied in Emergency Medicine residents using simulated consultation scenarios.OBJECTIVE:Using an experimental design, we aimed to evaluate the efficacy of the 5Cs consultation model in a novel learner population (medical students) and in a "real time and real world" clinical setting.METHODS:A prospective, randomized, controlled study was conducted at eight large, academic, urban, tertiary-care medical centers (U.S. and Canada). Intervention involved two experimental groups (asynchronous and live training) compared to a baseline control group. All participants placed up to four consult phone calls. A senior physician observed and assessed each call using a preapproved 5Cs checklist and a Global Rating Scale (GRS).RESULTS:Participants who received training (asynchronous or live) scored significantly higher on the 5Cs checklist total and GRS than the control group. Both training methods (asynchronous and live) were equally effective. Importantly, learning gains were sustained as students' 5Cs checklist total and GRS scores remained consistently higher at their second, third, and fourth consult (relative to their first consult). At posttest, all participants reported feeling more confident and competent in relaying patient information.CONCLUSION:Medical students can be trained to use the 5Cs model in a timely, inexpensive, and convenient manner and increase effectiveness of physician consultations originating from the ED.

Simulation is a fully immersive modality of education tailor-made for adult learners. After performing in simulated clinical scenarios, formal debriefing allows learners to engage in deep reflection which provides the framework to change dangerous practice patterns and improve future clinical performance. Clarifying the role of learning goals after simulation sessions has the potential to further improve the impact of simulation-based education. The objective of this study was to determine if providing formalized instruction on the creation of Specific, Measurable, Achievable, Realistic, Time-bound learning goals (SMART LG) in the context of debriefing after simulation would result in more self-directed learning compared to standard debriefing techniques.

Study ObjectivesRecent evidence suggests patients are unable to distinguish severity of illness or appropriateness of emergency department (ED) visits based on their presenting complaints. Many patients seek access to outpatient care prior to their ED visit, but there is little evidence to suggest that doing so leads to a more appropriate or "informed" triage decision. A marker of appropriateness of ED visits may be admission rate. This study will determine whether admission rates differ between patients who self-triage to the ED compared to those who are sent there by a health care provider, and whether there is a difference based on the type of outpatient provider contact patients experienced.MethodsA prospective cross-sectional study of adult ED patients who presented to a single tertiary care referral Level I trauma center with 115,000 annual ED visits. Consenting patients in the ED were surveyed during regular intervals during days and evenings 7 days/week. The survey was pilot-tested and validated in the target population. Patients were asked whether they had attempted to contact an outside provider prior to their ED visit, and if successful, what type of provider they contacted, whether it was in person or by phone, and what instructions they received. Responses were then matched with ED disposition data. Those patients physically seen in an office or medical aid unit, or told by phone to go the ED were considered "sent" to the ED. They were compared with the group that "self-triaged." Patients were considered to have had an "informed" decision to be sent to the ED if they were seen in person or spoke with a doctor by phone. Pearson's Chi-Square testing was used to determine associations between the type of outpatient provider contact and ED disposition.ResultsThere was no difference in admission rate between those who attempted to contact their doctors (98/207, 47%) and those who did not (122/151, 48%). There was no difference between those sent to the ED (86/166, 51%) and those who self-triaged (134/292, 46%). However, amongst those who were sent to the ED after phone contact, there was a higher admission rate in those who had spoken to a doctor (25/38, 66%) as compared to those who had spoken to a non-physician such as a receptionist, nurse, or midlevel provider (23/61, 38%), p<0.01. Patients who received an informed decision to be sent to the ED were more likely to be admitted (59/99, 60%) than others who were sent to the ED (23/61, 38%), p<0.01.ConclusionsPatients who seek outpatient care prior to their ED visit are admitted to the hospital just as often as those who self-triage. This supports recent studies demonstrating the inability of patients to determine the appropriateness of an ED visit. Some patients may be sent to an ED for testing or interventions not otherwise available as an outpatient. But, if admission rate is an indicator of appropriateness of ED visits, then a more informed decision to send the patient to the ED may reduce avoidable ED utilization. Patients who are physically seen by a provider, or at least speak to a physician by phone, are more likely to be admitted, compared with those who are directed to the ED by a non-physician over the phone. This suggests that improving patients' access to a physician, at least by phone, or expanding acute unscheduled care options for both assessments and advanced testing, may reduce ED visits that do not require hospital admission. Study ObjectivesRecent evidence suggests patients are unable to distinguish severity of illness or appropriateness of emergency department (ED) visits based on their presenting complaints. Many patients seek access to outpatient care prior to their ED visit, but there is little evidence to suggest that doing so leads to a more appropriate or "informed" triage decision. A marker of appropriateness of ED visits may be admission rate. This study will determine whether admission rates differ between patients who self-triage to the ED compared to those who are sent there by a health care provider, and whether there is a difference based on the type of outpatient provider contact patients experienced. Recent evidence suggests patients are unable to distinguish severity of illness or appropriateness of emergency department (ED) visits based on their presenting complaints. Many patients seek access to outpatient care prior to their ED visit, but there is little evidence to suggest that doing so leads to a more appropriate or "informed" triage decision. A marker of appropriateness of ED visits may be admission rate. This study will determine whether admission rates differ between patients who self-triage to the ED compared to those who are sent there by a health care provider, and whether there is a difference based on the type of outpatient provider contact patients experienced. MethodsA prospective cross-sectional study of adult ED patients who presented to a single tertiary care referral Level I trauma center with 115,000 annual ED visits. Consenting patients in the ED were surveyed during regular intervals during days and evenings 7 days/week. The survey was pilot-tested and validated in the target population. Patients were asked whether they had attempted to contact an outside provider prior to their ED visit, and if successful, what type of provider they contacted, whether it was in person or by phone, and what instructions they received. Responses were then matched with ED disposition data. Those patients physically seen in an office or medical aid unit, or told by phone to go the ED were considered "sent" to the ED. They were compared with the group that "self-triaged." Patients were considered to have had an "informed" decision to be sent to the ED if they were seen in person or spoke with a doctor by phone. Pearson's Chi-Square testing was used to determine associations between the type of outpatient provider contact and ED disposition. A prospective cross-sectional study of adult ED patients who presented to a single tertiary care referral Level I trauma center with 115,000 annual ED visits. Consenting patients in the ED were surveyed during regular intervals during days and evenings 7 days/week. The survey was pilot-tested and validated in the target population. Patients were asked whether they had attempted to contact an outside provider prior to their ED visit, and if successful, what type of provider they contacted, whether it was in person or by phone, and what instructions they received. Responses were then matched with ED disposition data. Those patients physically seen in an office or medical aid unit, or told by phone to go the ED were considered "sent" to the ED. They were compared with the group that "self-triaged." Patients were considered to have had an "informed" decision to be sent to the ED if they were seen in person or spoke with a doctor by phone. Pearson's Chi-Square testing was used to determine associations between the type of outpatient provider contact and ED disposition. ResultsThere was no difference in admission rate between those who attempted to contact their doctors (98/207, 47%) and those who did not (122/151, 48%). There was no difference between those sent to the ED (86/166, 51%) and those who self-triaged (134/292, 46%). However, amongst those who were sent to the ED after phone contact, there was a higher admission rate in those who had spoken to a doctor (25/38, 66%) as compared to those who had spoken to a non-physician such as a receptionist, nurse, or midlevel provider (23/61, 38%), p<0.01. Patients who received an informed decision to be sent to the ED were more likely to be admitted (59/99, 60%) than others who were sent to the ED (23/61, 38%), p<0.01. There was no difference in admission rate between those who attempted to contact their doctors (98/207, 47%) and those who did not (122/151, 48%). There was no difference between those sent to the ED (86/166, 51%) and those who self-triaged (134/292, 46%). However, amongst those who were sent to the ED after phone contact, there was a higher admission rate in those who had spoken to a doctor (25/38, 66%) as compared to those who had spoken to a non-physician such as a receptionist, nurse, or midlevel provider (23/61, 38%), p<0.01. Patients who received an informed decision to be sent to the ED were more likely to be admitted (59/99, 60%) than others who were sent to the ED (23/61, 38%), p<0.01. ConclusionsPatients who seek outpatient care prior to their ED visit are admitted to the hospital just as often as those who self-triage. This supports recent studies demonstrating the inability of patients to determine the appropriateness of an ED visit. Some patients may be sent to an ED for testing or interventions not otherwise available as an outpatient. But, if admission rate is an indicator of appropriateness of ED visits, then a more informed decision to send the patient to the ED may reduce avoidable ED utilization. Patients who are physically seen by a provider, or at least speak to a physician by phone, are more likely to be admitted, compared with those who are directed to the ED by a non-physician over the phone. This suggests that improving patients' access to a physician, at least by phone, or expanding acute unscheduled care options for both assessments and advanced testing, may reduce ED visits that do not require hospital admission. Patients who seek outpatient care prior to their ED visit are admitted to the hospital just as often as those who self-triage. This supports recent studies demonstrating the inability of patients to determine the appropriateness of an ED visit. Some patients may be sent to an ED for testing or interventions not otherwise available as an outpatient. But, if admission rate is an indicator of appropriateness of ED visits, then a more informed decision to send the patient to the ED may reduce avoidable ED utilization. Patients who are physically seen by a provider, or at least speak to a physician by phone, are more likely to be admitted, compared with those who are directed to the ED by a non-physician over the phone. This suggests that improving patients' access to a physician, at least by phone, or expanding acute unscheduled care options for both assessments and advanced testing, may reduce ED visits that do not require hospital admission.

OBJECTIVES:Emergency medicine (EM) faculty often aim to improve resident performance by enhancing the quality and delivery of feedback. The acceptance and integration of external feedback is influenced by multiple factors. However, it is interpreted through the "lens" of the learner's own self-assessment. Ideally, following an educational activity with feedback, a learner should be able to generate and act upon specific learning goals to improve performance. Examining the source of generated learning goals, whether from one's self-assessment or from external feedback, might shed light on the factors that lead to improvement and guide educational initiatives. Using a standard oral board scenario, the objective of this study was to determine the effects that residents' self-assessment and specific feedback from faculty have on not only the generation of learning goals but also the execution of these goals for performance improvement.METHODS:In this cross-sectional educational study at four academic programs, 72 senior EM residents participated in a standardized oral board scenario. Following the scenario, residents completed a self-assessment form. Next, examiners used a standardized checklist to provide both positive and negative feedback. Subsequently, residents were asked to generate "SMART" learning goals (specific, measurable, attainable, realistic, and time-bound). The investigators categorized the learning goals as stemming from the residents' self-assessments, feedback, or both. Within 4 weeks, the residents were asked to recall their learning goals and describe any actions taken to achieve those goals. These were grouped into similar categories. Descriptive statistics were used to summarize the data.RESULTS:A total of 226 learning goals were initially generated (mean ± SD = 3.1 ± 1.3 per resident). Forty-seven percent of the learning goals were generated by the residents' self-assessments only, while 27% were generated by the feedback given alone. Residents who performed poorly on the case incorporated feedback more often than high performers when generating learning goals. Follow-up data collection showed that 62 residents recalled 89 learning goals, of which 52 were acted upon. On follow-up, the numbers of learning goals from self-assessment and feedback were equal (25% each, 13 of 52), while the greatest number of reportedly executed learning goals came from self-assessments and feedback in agreement (40%).CONCLUSIONS:Following feedback on an oral board scenario, residents generated the majority of their learning goals from their own self-assessments. Conversely, at the follow-up period, they recalled an increased number of learning goals stemming from feedback, while the largest proportion of learning goals acted upon stemmed from both feedback and self-assessments in agreement. This suggests that educators need to incorporate residents' self-assessments into any delivered feedback to have the greatest influence on future learning goals and actions taken to improve performance.