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potential for outcome bias suggests that outcomes should bestripped whenever possible from these cases, as well. Randompeer review, with outcomes removed, might ultimately provemost useful for generating consistent understanding of thequality of care actually provided.

In the realm of malpractice litigation, cases submitted forexpert review, particularly court-appointed expert review, mightalso be stripped of evidence of the outcome. In states thatrequire a certificate of merit or other preliminary review,removing details of the outcome might add appropriate nuanceto the process. Alternatively, expert review might requirecomparison with one or more similar cases, each with unknownoutcomes, hiding the actual case and therefore the actualoutcome from the reviewer.

Stripping real cases of information about their outcomesbefore review comes with its own challenges. Most case reviewallows full access to the medical record, an approach that couldarguably emphasize outcomes bias as complications lead to moreextensive documentation. How to develop cases with sufficientdetail for review but without the detail that leads to bias willrequire its own investigation.

Stephen M. Schenkel, MD, MPPDepartment of Emergency MedicineUniversity of Maryland School of MedicineDepartment of Emergency MedicineMercy Medical CenterBaltimore, MD

doi:10.1016/j.annemergmed.2011.05.022

Funding and support: By Annals policy, all authors are required todisclose any and all commercial, financial, and other relationshipsin any way related to the subject of this article as per ICMJEconflict of interest guidelines (see www.icmje.org). The author isan unpaid board member of the Maryland Patient Safety Center.

1. Gupta M, Schriger DL, Tabas JA. The presence of outcome bias inemergency physician retrospective judgments of the quality of care.Ann Emerg Med. 2011;57:323-328.

2. Wears RL, Nemeth CP. Replacing hindsight with insight: towardbetter understanding of diagnostic failures. Ann Emerg Med. 2007;49:206-209.

3. Schenkel SM. Morbidity and mortality conference and patientsafety in emergency medicine. In: Croskerry P, Cosby KS, SchenkelSM, et al, eds. Patient Safety in Emergency Medicine. Philadelphia,PA: Lippincott Williams & Wilkins; 2009:295-301.

In reply:We thank Dr. Schenkel for his kind letter and endorse his

recommendations for limiting outcome bias from a number ofeducation, clinical, and medicolegal settings. Dr. Schenkel’s ideasrepresent the type of discussion that we had hoped would occur as aresult of our research. We encourage other readers to similarly

develop and apply their ideas for limiting outcome bias. d

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alkeet Gupta, MD, MSavid L. Schriger, MD, MPHCLA Emergency Medicine CenterCLA School of Medicineos Angeles, CA

effrey A. Tabas, MDCSF School of Medicine

an Francisco, CA

oi:10.1016/j.annemergmed.2011.05.023

unding and support: By Annals policy, all authors are required toisclose any and all commercial, financial, and other relationships

n any way related to the subject of this article as per ICMJEonflict of interest guidelines (see www.icmje.org). Dr. Schriger isupported by an unrestricted grant from the Korein Foundation.

esponse to New US Medical Schools to Openoors

To the Editor:I applaud Jan Greene’s “New US Medical Schools to Open

oors: But Residency Shortage Still the Bottleneck,” especiallyer analysis of how the recent and projected growth in medicalducation will solve neither the challenges associated withurrent residency slot restrictions nor the geographicaldistribution of physicians practicing in the United States.In addition to the growth among MD schools Ms. Greene

iscusses, osteopathic medical colleges also are growing. Duringhe last decade, osteopathic medical education has grown from9 colleges with just over 10,300 students to 26 colleges withore than 19,400 students. The nation’s 26 colleges of

steopathic medicine, 4 branch campuses, and 4 additionaleaching sites are now educating more than 20% of all new USedical students.Osteopathic medical schools graduated 3,631 new physicians

n 2010, a number that is expected to increase to 5,849 by019. Some 360 (nearly 10%) of last year’s graduatingsteopathic physicians (DOs) entered emergency medicineesidencies, a number that will increase as the number of newOs entering the workforce increases annually.Colleges of osteopathic medicine have a long history of

edication to training physicians to work in America’s smallerommunities, rural areas, and underserved urban areas, allowingOs to have a greater influence on the US population’s health

nd well-being than their numbers would suggest.I am hopeful that, with the help of the nation’s growing

umber of DO and MD medical colleges and the emergencyhysicians they graduate, and with support from the federalovernment agencies that are being encouraged to broadenrograms to improve both residency funding and the

istribution of US physicians, we can avert a crisis.

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The American Association of Colleges of OsteopathicMedicine represents the 26 US colleges of osteopathic medicineand their faculties, students, and administrators.

Stephen C. Shannon, DO, MPHAmerican Association of Colleges of Osteopathic Medicine

Chevy Chase, MD h

500 Annals of Emergency Medicine

oi:10.1016/j.annemergmed.2011.05.026

unding and support: By Annals policy, all authors are required toisclose any and all commercial, financial, and other relationships

n any way related to the subject of this article as per ICMJEonflict of interest guidelines (see www.icmje.org). The author

as stated that no such relationships exist.

IMAGES IN EMERGENCY MEDICINE(continued from p. 496)

DIAGNOSIS:Black widow spider bite. The insect was identified as a black widow spider because the patient brought it with

him to the emergency department. The patient was treated with multiple dosages of intravenous diazepam andmorphine for pain control and control of his hypertension and tachycardia. He improved overnight and wasdischarged home in good condition, not requiring administration of antivenin.

Volume , . : November