CJEM Articles: Glen Bandiera

Objective: We sought to characterize the perceptions of emergency medicine (EM) residents and fellows of their clinical and procedural competence, as well as their attitudes, practices and perceived barriers to reporting these perceptions to their supervisors.

Methods: A Web-based survey was distributed to residents and fellows, via their residency directors, in all Canadian EM residency programs outside of Quebec.

Results: Of 220 residents and fellows contacted in 9 of 10 EM programs of the Royal College of Physicians and Surgeons of Canada and 12 of 13 EM programs of The College of Family Physicians of Canada, 82 (37.3%) completed all or part of the survey. Response rates varied slightly by question; 25 of 82 re­spondents (30.5% [95% confidence interval (CI) 19.9%–41.1%]) agreed with the statement, “I sometimes feel unsafe or un­qualified with undertaking unsupervised responsibilities or procedures, but I do not report this to my senior physician” and 32 of 81 (39.5% [95% CI 28.2%–50.8%]) had felt this within the past 6 months. Moreover, 34 of 82 (41.5% [95% CI 30.2%–52.7%]) reported their lack of competence to a supervisor half the time or less. Trainees reported worry about loss of trust, autonomy or respect (38/80, 47.5% [95% CI 35.9%–59.1%]) or reputation (32/80, 40.0% [95% CI 28.6%–51.4%]). Nights on-call (30/79, 38% [95% CI 26.6%–49.3%]), admission decisions (13/79, 16.5% [7.6%–25.3%]) and central line insertion (13/79, 16.5% [95% CI 7.6%–25.3%]) were reported to be frequently undertaken despite not feeling competent. Suggestions to improve reporting included encouragement to report without penalty (41/82, 50.0% [95% CI 38.6%–61.4%]) and a less judgmental environment (32/82, 39.0% [95% CI 27.9%–50.2%]).

Conclusion: Emergency medicine trainees report that they frequently do not feel competent when undertaking responsibilities without supervision. Barriers to reporting these feelings or reporting adverse events appear to relate to social pressures and authority gradients. Modifications to the training culture are encouraged to improve patient safety.

How do we define competence in emergency medicine (EM), and how do we know when a resident has achieved it? In recent years, the idea of physician competence has become widely recognized as being multidimensional. This has resulted in an emphasis on competency-based education and assessment. We describe an up-to-date model to assess competence in EM. An overview of appropriate EM assessment tools is provided, along with their significant strengths and limitations. Sample behaviours representative of core competencies commonly assessed in EM training are matched to appropriate assessment tools. This review may serve as an introductory resource for EM clinicians, teachers and educators involved in EM trainee assessment.

Background: Faculty development initiatives to improve emergency department (ED) teaching are compromised by the paucity of information about what behaviours and characteristics are desirable in an emergency medicine (EM) teacher.

Objectives: To design and evaluate a learner-centred, interactive faculty development workshop based on original ED teaching research.

Methods: Registrants for a university-based faculty development workshop on ED teaching completed a needs assessment and pre-workshop self-reflection exercise. Responses were grouped into 3 themes derived from the ambulatory teaching literature and a recent survey of expert clinical EM teachers and learners. Participants underwent a half-day workshop consisting of 1 large group interactive session and 3 small group sessions using role playing, practice reflection, real time review of hard copy resources, and brainstorming. Evaluation included a post-event ordinal scale questionnaire and a 4-month follow-up short answer survey, both measuring participants' perceptions of workshop effectiveness.

Results: Fifteen faculty participated. The needs assessment identified "Common mistakes," "Teaching efficiently" and "Dealing with the difficult learner" as themes. All 15 completed evaluations, rating the workshop as relevant (4.6/5), specific to their needs (4.4/5) and useful (4.5/5). At 4 months, 10 out of 10 respondents reported success at implementing new techniques and 8 reported greater confidence in teaching. The most common new techniques were: setting better learning objectives, giving better feedback, actively seeking teaching opportunities, and identifying a teaching point.

Conclusions: Learner-centred faculty development meets perceived needs of faculty and can result in participants trying new teaching strategies.

Emergency physicians (EPs) are uniquely positioned to act as health advocates for individual patients, emergency department (ED) patient populations and the Canadian public. However, most ED practice environments do not encourage health advocacy, and staff EPs often do not feel adequately prepared to address many health-determinant issues. The mandate to provide health advocacy training to emergency medicine residents must be addressed in light of these challenges. This report defines the role of EPs as health advocates and summarizes the advantages and disadvantages of the ED as a forum for advocacy. At the University of Toronto, we have developed a new curriculum using evidence-based ED initiatives, examples of Canadian EP advocacy, and a description of organizations involved in advocacy, and we have incorporated several principles of adult learning to increase learner investment, maximize relevancy for EPs and optimize retention into practice. Residents believe the curriculum is highly relevant, allowing them to recognize advocacy opportunities in their own practices.