2
from initial patient contact to disposition is a surrogate metric of emergency medicine resident efficiency. We sought to determine if time to complete patient care changed between PGY level of experience. Methods: Performance data for 44 emergency medicine residents in an urban PGY 1-4 emergency medicine residency program were obtained from electronic patient tracking and order entry software. Data from a continuous 29-month period were included in the study. Time to complete care was measured as the difference in minutes between the time a resident electronically selected a patient in the tracking program to the time at which a disposition was assigned. The tracking program recorded a timestamp specific to each of these events for all patient encounters. Results were analyzed with descriptive statistics and the Wilcoxon signed rank test. Results: Mean time to complete care was measured for individual residents at each PGY level for each of the emergency medicine rotations in the study period. Mean time to complete care was also determined for groups of residents at each PGY level. PGY 3 residents had the lowest mean time to complete care (209.1 min, 16.5); PGY 4 residents had the highest (224.1 min, 13.6), with intermediate means for PGY 1 (212.4 min, 21.1) and PGY 2 (219.7 min, 20.0) residents. Within each PGY level, individual residents varied by up to 33% in mean time to complete care (190 min versus 281 min). Significant differences in mean time to complete care were observed between PGY 2 and 3 residents (10.6 min; z 2.08, 0.05) and PGY 3 and 4 residents (15 minutes; z 3.17, 0.05), but there was no overall trend to decreased time to disposition (or completion of care) with advancing PGY level. Conclusion: The time required for emergency medicine residents to complete care and disposition patients varies within and between PGY level. No significant decrease in the mean time required to disposition patients was detected with increasing level of training. Educational efforts aimed at teaching techniques to decrease time to disposition may translate into improved resident efficiency. 423 Not Your Grandmother’s Doctor Show: Bioethics and Professionalism in Television Medical Dramas Shaheen M, Brown A, Huynh V, McNinch D, Jones JS/MSU College of Human Medicine, Grand Rapids, MI; Grand Rapids MEP/Michigan State University, Grand Rapids, MI Study Objective: Television medical dramas are tremendously popular. In order to assess the possible affect of these dramas on the perceptions of the general public and their potential value in the education of residents and students, it is first necessary to identify what is actually portrayed in these programs. The purpose of this study was to systematically analyze the bioethical and professionalism content of popular medical dramas on television. Methods: In this retrospective cross-sectional study, consecutive TV episodes of 11 popular television programs (eg, House, Boston Med, ER) were viewed to identify all incidents in the programs that involved ethical issues, as well as those involving questions of interpersonal relations or professionalism. The most recent, complete season of each TV program was analyzed (total, 186 episodes). An incident was defined as a conversation between, or actions taken by, characters that involved a bioethics or professionalism issue. Our classification scheme for bioethical incidents was adapted from a recent study by the Johns Hopkins Institute of Bioethics (19 categories); our codes for professionalism were adapted from an Association of American Medical Colleges report (18 categories). Since it was not feasible to evaluate every interaction over the course of the 135 episodes, we limited our coding to those interactions that were exceptional or conspicuously offensive. After coding, all incidents were characterized as “negative” in the sense of violating a norm or “positive” by exemplifying it. A second investigator performed a blinded critical review of a random sample of 10% of the programs to determine reliability using kappa statistics. Descriptive statistics (95% confidence intervals) and frequency tables were used describe data. Results: A total of 186 TV episodes were analyzed: 340 bioethical incidents (mean, 1.8 incidents/TV episode) and 829 professionalism issues (4.5/TV episode) were identified. The same 4 programs with the most bioethical incidents also had the most issues involving professionalism. Consent was the most frequently observed bioethical issue. Of 37 total incidents, 43% (16/37) involved exemplary consent discussions, while the remainder were inadequate, such as physicians lying to patients in order to obtain consent. There were 33 incidents of ethically questionable departures from standard practice. Most of these incidents depicted physicians acting unethically in their pursuit of a favorable outcome for a patient. The majority of professionalism issues (66%) were negative. Incidents relating to sensitivity to patient’s pain, emotional state, physician integrity, risk-taking, and sex/ethnicity issues were the most frequently observed across all the series. Caring and compassion when dealing with patients was particularly noteworthy, because it is the only virtue of professionalism identified in which the exemplary portrayals outnumbered the lapses in professionalism. Conclusion: Television medical dramas contain many perplexing ethical issues and examples of egregious professionalism which, in an educational setting, could help to engage students and residents in discussions of the appropriate management of such issues. Unfortunately, the general public will inadvertently pick up on details that will shape their understanding of the medical profession - good or bad. 424 Type and Level of Resident Education Affects Emergency Department Patient Satisfaction Miller MP, Chacko B, Nugent A, Harland K, Denning G/University of Iowa, Iowa City, IA Study Objectives: To compare the results of patient satisfaction scores based on the proportion of hours per month worked by off service (non-emergency medicine) residents rotating in the emergency department (ED) or by second year emergency medicine (EM) residents serving as the senior resident on the team. Methods: Monthly data for a study period from July 2011 through February 2012 were compiled. To determine the potential impact of off-service residents on patient satisfaction scores, the percentage of shifts/month worked by these residents was determined and months were divided into 2 groups, 30% or 30% of total resident shifts staffed by off-service residents. The average Press Ganey® satisfaction scores for the doctor section of the surveys were compared for these 2 groups. Similarly, to determine the potential impact of a second-year emergency medicine resident as the senior resident, the average Press Ganey® scores were compared for months where a greater proportion of shifts (50%) were to second-year versus third-year emergency medicine residents. Results: When 30% of the total resident shifts each month were staffed by off- service residents, the average patient satisfaction score was 81.8, as compared to a score of 85.4 for months when they represented 30% of shifts staffed (p0.07). Similarly, when 2nd-year emergency medicine residents worked a greater proportion of shifts (50%) when compared to 3rd-year emergency medicine residents, the mean patient satisfaction score was 80.9, as compared to 85.1 when 3rd-year residents worked a greater proportion of shifts in a month (p0.04). Conclusions: Based on these preliminary data, we hypothesize that non- emergency medicine training and senior residents with less emergency medicine training (second-year versus third-year emergency medicine residents) are associated with reduced patient satisfaction scores. Future studies will include expanding the study period to further test this hypothesis. If the hypothesis proves true, improving off-service resident orientation prior to starting an emergency medicine rotation, as well as balancing the staffing model of second and third-year emergency medicine residents may improve patient satisfaction scores. 425 Case-based Simulation: Critical Conversations Around Resuscitation of the Critically Ill or Injured Patient Lamba S, Nagurka R, Offin M, Compton S/The University of Medicine and Dentistry of New Jersey, Newark, NJ Study Objectives: Educational module objectives to enhance communication with family: 1. To practice skills of clear/direct, closed-loop communication with interdisciplinary teams (simulated resuscitation) 2. To enhance skills and use appropriate behaviors (responding to emotion, comforting someone in emotional shock) when breaking bad news/delivering news of death to survivors (simulation/role-play) 3. To foster skills of self-reflection in order to identify processes for improvement and manage emotional responses Methods: Educational module includes: 1. Case-based simulated-resuscitation session Didactics: reinforce closed-loop communication; introduce self-reflection and highlight family-centered communication skills Trainee practice of ACLS/ATLS skills with a simulated patient: Cardiac arrest with patient death; Massive blunt trauma with uncertain prognosis 2. Role-play as physician and/or family members of the simulated patient and deliver news of death or poor prognosis to survivors Research Forum Abstracts Volume , . : October Annals of Emergency Medicine S149

425 Case-based Simulation: Critical Conversations Around Resuscitation of the Critically Ill or Injured Patient

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from initial patient contact to disposition is a surrogate metric of emergency medicineresident efficiency. We sought to determine if time to complete patient care changedbetween PGY level of experience.

Methods: Performance data for 44 emergency medicine residents in an urbanPGY 1-4 emergency medicine residency program were obtained from electronicpatient tracking and order entry software. Data from a continuous 29-month periodwere included in the study. Time to complete care was measured as the difference inminutes between the time a resident electronically selected a patient in the trackingprogram to the time at which a disposition was assigned. The tracking programrecorded a timestamp specific to each of these events for all patient encounters.Results were analyzed with descriptive statistics and the Wilcoxon signed rank test.

Results: Mean time to complete care was measured for individual residents ateach PGY level for each of the emergency medicine rotations in the study period.Mean time to complete care was also determined for groups of residents at each PGYlevel. PGY 3 residents had the lowest mean time to complete care (209.1 min, �16.5); PGY 4 residents had the highest (224.1 min, � 13.6), with intermediatemeans for PGY 1 (212.4 min, � 21.1) and PGY 2 (219.7 min, � 20.0)residents. Within each PGY level, individual residents varied by up to 33% in meantime to complete care (190 min versus 281 min). Significant differences in mean timeto complete care were observed between PGY 2 and 3 residents (�10.6 min; z �2.08, � � 0.05) and PGY 3 and 4 residents (15 minutes; z � 3.17, � � 0.05), butthere was no overall trend to decreased time to disposition (or completion of care)with advancing PGY level.

Conclusion: The time required for emergency medicine residents to completecare and disposition patients varies within and between PGY level. No significantdecrease in the mean time required to disposition patients was detected withincreasing level of training. Educational efforts aimed at teaching techniques todecrease time to disposition may translate into improved resident efficiency.

423 Not Your Grandmother’s Doctor Show: Bioethics andProfessionalism in Television Medical Dramas

Shaheen M, Brown A, Huynh V, McNinch D, Jones JS/MSU College of HumanMedicine, Grand Rapids, MI; Grand Rapids MEP/Michigan State University,Grand Rapids, MI

Study Objective: Television medical dramas are tremendously popular. In orderto assess the possible affect of these dramas on the perceptions of the general publicand their potential value in the education of residents and students, it is first necessaryto identify what is actually portrayed in these programs. The purpose of this studywas to systematically analyze the bioethical and professionalism content of popularmedical dramas on television.

Methods: In this retrospective cross-sectional study, consecutive TV episodes of11 popular television programs (eg, House, Boston Med, ER) were viewed to identifyall incidents in the programs that involved ethical issues, as well as those involvingquestions of interpersonal relations or professionalism. The most recent, completeseason of each TV program was analyzed (total, 186 episodes). An incident wasdefined as a conversation between, or actions taken by, characters that involved abioethics or professionalism issue. Our classification scheme for bioethical incidentswas adapted from a recent study by the Johns Hopkins Institute of Bioethics (19categories); our codes for professionalism were adapted from an Association ofAmerican Medical Colleges report (18 categories). Since it was not feasible to evaluateevery interaction over the course of the 135 episodes, we limited our coding to thoseinteractions that were exceptional or conspicuously offensive. After coding, allincidents were characterized as “negative” in the sense of violating a norm or“positive” by exemplifying it. A second investigator performed a blinded criticalreview of a random sample of 10% of the programs to determine reliability usingkappa statistics. Descriptive statistics (95% confidence intervals) and frequency tableswere used describe data.

Results: A total of 186 TV episodes were analyzed: 340 bioethical incidents(mean, 1.8 incidents/TV episode) and 829 professionalism issues (4.5/TV episode)were identified. The same 4 programs with the most bioethical incidents also had themost issues involving professionalism. Consent was the most frequently observedbioethical issue. Of 37 total incidents, 43% (16/37) involved exemplary consentdiscussions, while the remainder were inadequate, such as physicians lying to patientsin order to obtain consent. There were 33 incidents of ethically questionabledepartures from standard practice. Most of these incidents depicted physicians actingunethically in their pursuit of a favorable outcome for a patient. The majority ofprofessionalism issues (66%) were negative. Incidents relating to sensitivity topatient’s pain, emotional state, physician integrity, risk-taking, and sex/ethnicity

issues were the most frequently observed across all the series. Caring and compassionwhen dealing with patients was particularly noteworthy, because it is the only virtueof professionalism identified in which the exemplary portrayals outnumbered thelapses in professionalism.

Conclusion: Television medical dramas contain many perplexing ethicalissues and examples of egregious professionalism which, in an educational setting,could help to engage students and residents in discussions of the appropriatemanagement of such issues. Unfortunately, the general public will inadvertentlypick up on details that will shape their understanding of the medical profession -good or bad.

424 Type and Level of Resident Education AffectsEmergency Department Patient Satisfaction

Miller MP, Chacko B, Nugent A, Harland K, Denning G/University of Iowa, IowaCity, IA

Study Objectives: To compare the results of patient satisfaction scores based onthe proportion of hours per month worked by off service (non-emergency medicine)residents rotating in the emergency department (ED) or by second year emergencymedicine (EM) residents serving as the senior resident on the team.

Methods: Monthly data for a study period from July 2011 through February2012 were compiled. To determine the potential impact of off-service residents onpatient satisfaction scores, the percentage of shifts/month worked by these residentswas determined and months were divided into 2 groups, �30% or �30% of totalresident shifts staffed by off-service residents. The average Press Ganey® satisfactionscores for the doctor section of the surveys were compared for these 2 groups.Similarly, to determine the potential impact of a second-year emergency medicineresident as the senior resident, the average Press Ganey® scores were compared formonths where a greater proportion of shifts (�50%) were to second-year versusthird-year emergency medicine residents.

Results: When �30% of the total resident shifts each month were staffed by off-service residents, the average patient satisfaction score was 81.8, as compared to ascore of 85.4 for months when they represented �30% of shifts staffed (p�0.07).Similarly, when 2nd-year emergency medicine residents worked a greater proportionof shifts (�50%) when compared to 3rd-year emergency medicine residents, themean patient satisfaction score was 80.9, as compared to 85.1 when 3rd-year residentsworked a greater proportion of shifts in a month (p�0.04).

Conclusions: Based on these preliminary data, we hypothesize that non-emergency medicine training and senior residents with less emergency medicinetraining (second-year versus third-year emergency medicine residents) are associatedwith reduced patient satisfaction scores. Future studies will include expanding thestudy period to further test this hypothesis. If the hypothesis proves true, improvingoff-service resident orientation prior to starting an emergency medicine rotation, aswell as balancing the staffing model of second and third-year emergency medicineresidents may improve patient satisfaction scores.

425 Case-based Simulation: Critical ConversationsAround Resuscitation of the Critically Ill or InjuredPatient

Lamba S, Nagurka R, Offin M, Compton S/The University of Medicine andDentistry of New Jersey, Newark, NJ

Study Objectives: Educational module objectives to enhance communicationwith family:

1. To practice skills of clear/direct, closed-loop communication withinterdisciplinary teams (simulated resuscitation)

2. To enhance skills and use appropriate behaviors (responding to emotion,comforting someone in emotional shock) when breaking bad news/delivering news ofdeath to survivors (simulation/role-play)

3. To foster skills of self-reflection in order to identify processes for improvementand manage emotional responses

Methods: Educational module includes:1. Case-based simulated-resuscitation session● Didactics: reinforce closed-loop communication; introduce self-reflection and

highlight family-centered communication skills● Trainee practice of ACLS/ATLS skills with a simulated patient: Cardiac arrest

with patient death; Massive blunt trauma with uncertain prognosis2. Role-play as physician and/or family members of the simulated patient and

deliver news of death or poor prognosis to survivors

Research Forum Abstracts

Volume , . : October Annals of Emergency Medicine S149

3. Self reflection: a written report after self-reflecting on a real/simulated familycommunication during resuscitation and trainee’s emotional response Outcomesassessed: pre-post clerkship survey; peer-observer feedback forms after role-play;qualitative analysis of self-reflections on resuscitation

Results: Themes emerging around resuscitation based self-reflections:1. Codes in ED are efficient and run like “well-oiled machines”2. Anxiety around resuscitation [“I knew it all and at that time (simulated ACLS)

but it was really hard to think through what should be done next”]3. Uncertainty about their own roles in both real and simulated resuscitation

scenariosConclusion: Though senior medical students may not receive specific training

in self-reflection skills, they value self-reflection as a tool for personal growth.Students often use electronic means to discuss clinical encounters that go welland those that do not. Improvement in scores related to medical student comfortand confidence with breaking bad news (death and poor prognosis) is seen afterintroducing a communication module to ACLS/ATLS skills training in anemergency medicine clerkship. Pre-existing modalities in use to teach thetechnical skills of ACLS/ATLS should be supplemented with interventions toimprove communication as well as self-reflection skills both during and afterresuscitations. Effective communication skills are necessary to meet the needs offamily survivors of a patient’s critical injury/illness.

426 Defining the Six ACGME Core CompetenciesAppropriate for Emergency Ultrasonography Training:An Emergency Ultrasonography Directors Survey

Poole CL, Sierzenski PR, Powell JT, Mink J, Cook D, Reed III JF, NomuraJT/Christiana Care, Newark, DE; Roper Bon Secours-St. Francis Hospital,Charleston, SC

Background: Emergency ultrasonography (EUS) training is mandated inemergency medicine residency programs (EMRP) by the Residency ReviewCommittee for Emergency Medicine (RRC-EM). EUS is one of 3 proceduralcompetencies that must be evaluated by EMRP. In 1999, the ACGME statedresidents must be competent in the 6 core competency (6CC) areas of: patient care,medical knowledge, practice-based learning and improvement, interpersonal andcommunication skills, professionalism, and systems-based practice. They also requiredevaluation of each resident in these 6CCs during their training.

Study Objectives: Rate the appropriateness of 25 EUS specific ACGME corecompetencies to better define the original 6 ACGME core competencies foremergency medicine residents, via a survey of EMRP EUS Directors (EUSDIR).

Methods: Following institutional review board approval, a prospective,anonymous pilot tested and validated electronic survey was distributed to ACGMEEUSDIRs (N � 104) by commercial software (SurveyMonkey®). Each EUSDIR wasasked to rank the appropriateness of 25 proposed metrics, using a 10-point numericscale (0�Not Appropriate, 5 � Appropriate, 10 � Extremely Appropriate).Descriptive statistics including mean, and standard deviation (SD) were calculated.

Results: 104 EUSDIR emails were identified and confirmed. 52 surveys were completedfor a 50% response rate. Mean rating of the proposed EUS defined ACGME 6CC �7.96(6.31-9.61). Table 1 reports the highest rated proposed EUS competency of each of the 6ACGME Core Competencies, including mean rating by EUSDIR, with standard deviation.

Conclusion: On average EUSDIRs rated proposed emergency ultrasonographyspecific core competencies that better define ACGME core competencies as veryappropriate. 17 of 25 (68%) of the proposed EUS specific core competencies wererated at or above the mean of 7.96 by EUSDIRs. Of note, none of the proposedsystems-based practice competencies scored above the mean.

ACGME Core Competency ClassicallyDefined Proposed “EUS Specific” Competency

EUSDIR Mean“Appropriateness

Rating”

Patient Care that is as compassionate,appropriate, and effective for thetreatment of health problems and thepromotion of health)

“Resident demonstrates effective use ofEUS protocols for life-savingapplications (E-FAST, Abdominal Aorta,Echo, Pelvic, & Procedural).”

8.85 (7.14–10.56)*

Medical Knowledge about establishedand evolving biomedical, clinical, andcognate (e.g. epidemiological andsocial-behavioral) sciences and theapplication of this knowledge topatient care

“Resident demonstrates understandingof how to incorpor ate EUSperformance and findings into clinicalcare.”

9.06 (7.45–10.67)*

Practice-Based Learning andImprovement that involvesinvestigation and evaluation of theirown patient care, appraisal andassimilation of scientific evidence,and improvements in patient care

“Resident participates in didactic,simulation, and/or bedside teaching toimprove any deficiencies in EUS.”

8.27 (6.42–10.12)*

Interpersonal and CommunicationSkills that result in effectiveinformation exchange and teamingwith patients, their families, andother health professionals

“Resident effectively communicates EUSfindings to a multi-specialty team(Trauma, Cardiology, Critical Care,Emergency Medicine).”

8.21 (6.11–10.31)*

Professionalism, as manifestedthrough a commitment to carrying outprofessional responsibilities,adherence to ethical principles, andsensitivity to a diverse patientpopulation

“Resident demonstrates compliancewith EUS equipment maintenance andinstitutional disinfection protocols.”

8.17 (5.98–10.36)*

Systems-Based Practice, asmanifested by actions thatdemonstrate an awareness of andresponsiveness to the larger contextand system of health care and theability to effectively call on systemresources to provide care that is ofoptimal value.

“Resident demonstrates communicationof EUS findings to inpatient care &consultant providers.”

7.63 (5.32–9.94)*

*Above overall survey appropriateness mean of 7.96 (6.31–9.61)

427 Evaluation of a Difficult Airway EducationalIntervention on Resident Intubation Performance

Avegno JL, Moreno-Walton L, Engle J, Roberts L, Myers L/Louisiana StateUniversity Health Sciences Center- New Orleans, New Orleans, LA; TulaneUniversity School of Public Health & Tropical Medicine, New Orleans, LA

Study Objectives: Successful emergency airway management is a criticalcomponent of emergency medicine (EM) residency training. emergency medicine

Research Forum Abstracts

S150 Annals of Emergency Medicine Volume , . : October