Council of Emergency Medicine Residency Directors

CPC Regional Competition

On May 16, fifty Emergency Medicine Residency Programs competed in the ninth Annual Regional CPC Competition. A resident from each participating program submitted a challenging unknown case for discussion by an attending from another residency program. The faculty discussion had 20 minutes to develop a differential diagnosis and explain the thought process leading to the final diagnosis. As always, the case presentations and discussions were excellent and well received by those in attendance. Unfortunately, only 5 resident presenters and 5 faculty discussants could be picked as winners.

Winning presenters and discussants were selected from each of five regions and these individuals will represent those regions at the national competition. The CPC finals will be held at the ACEP Scientific Assembly in San Diego on October 13 from 8:00-11:30 am. It is not necessary to register for the Scientific Assembly if you plan only to attend the CPC. The CPC Competition is sponsored by ACEP, CORD, EMRA, and SAEM.

Congratulations to the 1998 Regional Winners!

Region A (formerly Western Region)
Best Presenter: Amy Hutson, MD, Highland General Hospital
Best Discussant: Louis Durkin, MD, Baystate Medical Center

Region B (formerly Southern Region)
Best Presenter: Michelle Bache, MD, Methodist/Indiana University
Best Discussant: Pamela Ross, MD, University of Virginia

Region C (formerly Eastern Region)
Best Presenter: Samuel Connolly, MD, University of Massachusetts
Best Discussant: George Higgins, MD, Maine Medical Center

Region D (formerly Central Region)
Best Presenter: Allison Silver, MD, Temple University Hospital
Best Discussant: David Chuirazzi MD, Allegheny General Hospital

Region E (formerly Midwest Region)
Best Presenter: Sangita Rangala, MD, Cook County Hospital
Best Discussant: Rober Gerhardt, MD, Texas Tech

Thanks are due to the judges and regional coordinators for once again presenting a successful and stimulating Regional CPC Competition. The judges and coordinators were Terry Kowalenko, Karen Randall-Krystal, Leslie Wolf, Glenn Tokarsky, Judith Brillman, Brian Tiffany, Richard Hartoch, Eric Koscove, Peggy Goodman, Yolanda Haywood, Nick Jouriles, Mike Wade, Andy Jagoda, Dan Joyce, Scott Hill, Carol Barsky, Kevin Rodgers, Scott Doak, and Michael Beeson.

PRESIDENTS MESSAGE

Chicago and Beyond

I returned from the Chicago meeting, admittedly, exhausted but enthusiastic about CORD activities and prospects for the future. The CORD business meetings and educational participation by CORD members at SAEM has grown tremendously since the early days when we were organized around the regional roundtables. The activities and educational sessions at the SAEM meeting with CORD members participating have become incredible. The first day of the Chicago activities included the Chief's Resident Forum, the CPC, and the Medical Students Conference. These were all activities with CORD's membership highly visible. The attendance and excitement at the CPC reception was at an all time high. The New Residency Program Directors Workshop was another success. The CORD annual business meeting was held in a very large room to accommodate the large number of CORD members present. It appears that the CORD annual meeting participation has grown to be as big if not bigger than the actual SAEM business meeting itself. The inaugural first annual Emergency Medicine Coordinators meeting supported by CORD was also a success. It was really good to see the residency coordinators enthusiasm and effort to become more knowledgeable about the activities of residency programs.

Dr. David Leach, Director, ACGME was a guest speaker at the CORD meeting. I remember his quote "what ever we measure we tend to improve". We do have some real challenges ahead of us in terms of measuring procedural competencies of our residents and improving upon these competencies. There are challenges ahead of us to measure our core content and improve upon them. There are challenges ahead of us to measure the effectiveness of residency programs and improve upon them. Dr. Sulton, Executive Director of the RRC for Emergency Medicine, gave us several examples of what is to come regarding residency training/education from the perspective of the RRC. The RRC anticipates revised program requirements, competency based outcomes measurement of resident performance, increased emphasis on educational training goals and objectives, electronic application program (PIF) and emergency medicine newsletter. There is a summary of Dr. Sulton's report in this newsletter.

The updates by the American Board of Emergency Medicine representatives (Dan Danzl and Mary Ann Reinhart) were very informative and provided insight also on areas that we need to measure and improve regarding the training of our residents.

The session on the structured interview led by Ms. Gretchen Bellino was very informative and generated a lively discussion. A summary of that session will be printed in the newsletter at a later date.

During the CORD business meeting, I gave an overview of progress of our committees and task forces. Summaries of most of these task forces and committees were published in the last 2 newsletters. Summaries of the rest are provided in this newsletter. The Question and Answer Bank Task Force met at the CORD meeting and plans to have 800 questions (some old, some new) in our Q&A bank during the upcoming year. There are about 30 editors and item writers that consist of the Q&A Task Force. A brief report of the Q&A Task Force is printed in this newsletter. An ERAS update was given by Pam Dyne at the CORD meeting. There is a full report on ERAS activities in this newsletter.

We look forward to the finished product by the EKG Task Force. We anticipate the product will be available to the CORD membership by the fall meeting. There was an outstanding educational display by the EKG Task Force at the SAEM meeting. Generally, the quality of the EKGs demonstrated has markedly improved over the EKGs demonstrated a year ago. The CORD Board is reviewing the first draft of the manuscript by the Procedural Competencies Task Force. That manuscript will become available to the CORD membership after revision and publication. The Resident Support Task Force has preliminary drafts of the resident remediation and resident evaluation manuscripts. The CORD Board will be reviewing this preliminary material.

The CORD Board also met in Chicago with members of the American Board of Emergency Medicine and discussed the core content as well as scope of training issues. CORD must determine those elements of the curriculum that are outdated and those elements that need to be added.

We must take a close look at where we should be in five to ten years regarding training. It is hoped that as the Core Content Task Force II becomes organized that members of this group will ask the same questions and take a close look not only at the core content but what it means in terms of the curriculum for emergency medicine.

I am finalizing the CORD committees and task forces goals for 1998-99. Much of what we have been doing, we will continue. However, I am calling for renewed interest in the curriculum and asking that each CORD member look at the curriculum, dissect it, and give feedback to the Curriculum Committee Chair, Richard Krause, Buffalo General Hospital at or Curriculum Committee member Tim Evans of Medical College of Virginia at 804-225-3463. We will also survey the membership to glean the important areas and issues we should be addressing the upcoming years.

The resident representatives to the Organization of Resident Representatives meet at AAMC yearly. It is time to rotate our resident representatives off and select 2 new residents. I would like recommendations from the CORD membership regarding junior level residents interested in becoming representatives. It is my belief that we should have more participation by CORD membership at the annual AAMC meeting as well.

By the way, congratulations to Susan Dufel the newest CORD Board member and many thanks to Sandy Craig for her service on the CORD Board of Directors.

One of the highlights for me at SAEM was sessions on challenging teaching situations. There were several interesting cases discussed and it was good to know that many of us share the same common challenges when it comes to teaching off service residents as well as at our own residents at all levels. Although I was initially skeptical about the value of such session, I think the challenging teaching situation session should continue annually at the SAEM meeting.

Well, we are already looking towards the fall CORD meeting which will be upon us soon. Please send ideas for education sessions for the CORD meeting to Paul Pearigen, Chair of the Program Committee at pearigen@snd10.med.navy.mil. Have a nice summer.

Marcus Martin, MD
University of Virginia

ERAS Task Force Report and Update

The goals of the ERAS Task Force are two-fold. The first is to facilitate 100% participation in ERAS for EM residency programs. The second is to provide ongoing education, evaluation, and feedback and between the AAMC and the CORD membership. I feel that we have been very successful in meeting both of these goals.

We are proud to say that our first goal has been met; 100% of Emergency Medicine residencies are participating in ERAS 99 after approximately 95% participation in ERAS 98. This indicates that all programs who participated in ERAS 98 were satisfied and re-enrolled for ERAS 99, which suggests that the program is successful. This also indicates that all of the programs who chose not to participate in ERAS 98 were recruited, either through the educational efforts of the task force, from peer pressure, or both.

As a result of such uniform participation in ERAS and the nature of the electronic program, we are now able to collect and keep accurate information on the demographics of our applicant pool to Emergency Medicine. For ERAS 98, there were 2,016 applicants to EM programs, 1,526 of whom were US Medical Grads and 490 of whom were International Medical Grads. This, incidentally, is the lowest ratio (24%) of IMGs/total applicants of any specialty using ERAS. Across specialties using ERAS (OB/GYN, Family Medicine, Diagnostic Radiology, Transitional Internships, Prelim. Surgery, and Military programs), IMGs make up 35% of the applicants. This total ratio might change for the coming year, as Internal Medicine is coming on line for ERAS 99. Our 2,016 applicants submitted 42,658 applications, giving an average of 21 applications per applicant.

With respect to our second goal of providing feedback from CORD to the AAMC, I think we have also been very successful. The program manager of ERAS at the AAMC, Gwynne Kostin, has told me that our specialty has provided her with more useful feedback than any other specialty. They are very appreciative of this and are working diligently to incorporate as many of our suggestions as are feasible. As there is a relatively long development cycle for a program as complex as ERAS, some of our suggestions are incorporated into ERAS 99, but the vast majority won't be realized until ERAS 2000. Some of the changes that we will see in ERAS 99 that are the direct result of our comments and suggestions include:

1. Management of "bad files" The Post Office algorithm will skip over any applicant file that fails to electronically transfer after x number of attempts (I believe it is 5). The sending school will be notified by the Post Office of the problem and addressed at that level. Therefore, our download process will not be hindered as a result of these few bad files, as it was for many program directors last year.

2. There will be an option to view the applicant information in a format that resembles a CV, so there will be no need for applicants to include a CV as an addendum to their personal statement or one of their LORs.

3. There will be improv ed and facilitated portability of ERAS files by easily copy ing them onto Zip disk. This will allow in dividuals to view application materials on different comp uters than their central ERAS computer if they don 't otherwise have a LAN or remote access to their computer. The non-portability of the program files was a major problem for many programs this past year, and resulted in many people being forced to print out all the applications in order to review them in a timely fashion. Unfortunately, we will not be able to make comments or input information onto the Zip disks for incorporation into the main program yet, but this is planned for the next version. In the meantime, hand written comments on a form generated by ERAS that resembles the screen views for easy manual incorporation by an assistant is the best we can do. Use of a LAN or electronic remote access remain the best and most efficient methods of viewing the application information remotely.

4. We will see some improved navigation and document quality with ERAS 99, but much more will come with ERAS 2000. AAMC is working with the Medical School Deans' Offices to re-enforce the specifications that have already been suggested for document scanning. They are also working on incorporating a document viewing program like Adobe Reader into the ERAS 2000 program that should greatly improve scanned image quality and relieve a lot of our headaches.

Another relevant piece of information regarding ERAS 99 is the participation of Internal Medicine. They are expecting approximately twice the number of applicant users, with the result of at least a two-fold increase in the number of documents going through the Post Office. While they are expecting this and anticipate being able to handle it, we will all have to wait and see. Additionally, applicants can now apply to both the categorical and combined EM/IM programs via ERAS, though each program is format is referred to as a separate specialty by ERAS.

The timeline for ERAS 99 is as follows:
6/98 Shut down information sent to ERAS 98 users regarding options for archiving applicant info.

7/15/98 ERAS 98 applicant info dumped by the Post Office New ERAS 99 software available on disk, CD rom, or downloadable off the Web.

8/15/98 ERAS 99 Post Office opens

Future ERAS task force activities will include continued feedback to the AAMC from the CORD membership, as well as to work closely with the CORD SLOR Task Force to ultimately facilitate incorporation of the SLOR into ERAS. That, however, is a long-range goal, so an intermediate goal will be to improve the legibility of the SLOR within the current ERAS platform.

Pamela L. Dyne, MD
UCLA-Olive View
Chair, ERAS Task Force

A Report from the ERAS Control Group

In the most recent application cycle, 97% of the 119 Emergency Medicine Residency Programs participated in the Electronic Residency Application Service (ERAS). The Denver Health Medical Center Residency in Emergency Medicine was in the minority 3%. When I was asked why we were not participating, I usually replied that, "We had randomized to the control group." That seemed to satisfy most of the inquirers.

Actually, I had put the question of our participation before my Program Steering Committee in the fall of 1996. There was much discussion of the potential pros and cons, but the decision was made not to participate. Many reasons and concerns were mulled over, but it came down to worries about ERAS being able to accommodate the numbers of applications that it was going to receive. The Program Steering Committee was concerned about the reliability of the ERAS system that had not yet been tested at the volume that the expansion participating programs from several specialties was going to bring. Quite frankly, we thought there would be a larger percentage of residency programs that would share our concerns and not be participating in the first year.

We entered this application cycle with our fingers crossed, knowing that, being a non-ERAS program, applicants would have to obtain our application, fill it out) painstakingly, with their quill pens, by lamplight), affix proper postage, and drop it in an approved postal receptacle for "snail-mail" delivery. We were hoping that the effect of this process would primarily be on quantity and not on quality. We hoped that the strong, committed applicants who were genuinely interested in our program would invest the time and effort to apply, but not the casual, "Control-A, Select All" applicant. To be fair, the people at ERAS and CORD had told me about the escalating fee schedule for applicants that discourages such a problem. The experience with ERAS this year seems to indicate that it did, in fact, discourage applicants from applying to unreasonable numbers of programs.

So what happened? In 1996-97 (the last pre-ERAS year for emergency medicine) we received 681 applications for our 13 PGY-2 positions. That was an increase of 15.8% over the previous year. We screened all of the applications and invited all of the applicants who exceeded a certain benchmark to come for an interview. Thus, we invited 249 applicants to interview (an increase of 50.5% over the previous year). Of those invited, 197 applicants did finally interview with us. The mean number of interviews per applicant was 3.9.

This unprecedentedly large number of invitations and interviews created quite a bit of work for our staff and an investment of valuable time and travel expenses on the part of the applicants. It prompted a change in our invitation policy: we decided to move our application deadlines back by one week, raise our application screening benchmark to make it more difficult to receive an interview invitation, and limit both the number of interview days and interviewees per day (the first time we have ever used a waiting list).

These policy changes and our non-ERAS status seems to have altered our application experiences this year. We received a total of 336 applications (a decrease of 43% from the previous year). In speaking with some ERAS participating Program Directors, most were reporting a 15% to 25% decrease in applications this year compared to last. By any measure that we could look at, however, the quality of the applicants was as great or greater than in the previous year. Based on a review of the applications, we invited 162 people to interview with us: 132 accepted the offer (33% fewer than the previous year, but 4.5% more than the year before).

The conventional wisdom among some program directors is that 8 to 10 times the number of incoming positions is a good target for the number of applicants to interview. Using that strategy and assuming a similar percentage of applicants will decline their interview, we should invite 123 to 157 applicants for an interview, expecting to interview 104 to 130.

The 8 to 10 target may be more conservative than is necessary. We will list any applicant on our final Rank Order List that we can live with and none that we couldn't. Last year, we filled our 13 PGY-2 positions with the 41st person on our Rank Order List of 146 names. This year, we filled with the 30th person on our list of 96 names.

By not participating with ERAS, we also missed out on some of the ERAS bugs that bothered some of the other emergency medicine programs. I think you are all very familiar with the good and not-so-good aspects of ERAS that have been discussed in this newsletter, on the CORD e-mail list, and at the CORD Meetings over the past year.

Emergency Medicine Residencies seem to be doing very well in the matching process, but let's not fall prey to smugness. The percentages of filled PGY-1 positions in Emergency Medicine were 97% in 1994, 96.4% in 1995, 98.7% in 1996, 97.8% in 1997, and 94.1% this year. The percentages of filled PGY-2 (advanced match) positions in Emergency Medicine were 91.1% in 1994, 99.2% in 1995, 98.8% in 1996, 97.5% in 1997, and 93.3% this year. Although perhaps not a very reliable measure, our match rate this year was beaten by Dermatology, General Surgery, Internal Medicine, Obstetrics and Gynecology, Orthopedics, General Pediatrics, Plastic Surgery, and Radiation Oncology. Could it be that supply is meeting demand in emergency medicine? Could it be that the 934 PGY-1 Emergency Medicine positions and the 164 PGY-2 Emergency Medicine positions offered this year is approaching the number of interested graduating medical students? Does the future hold a bleaker outlook for Emergency Medicine Residency recruiting? I really can't say, but I can happily report that we will be leaving the control group: in the coming year we will begin the crossover phase of our study, fully participating in ERAS.

Lee W. Shockley, MD
Denver Health Medical Center

Making ERAS More Portable

Many residency directors have commented that they are either chained to their office computer in order to review the applicant files in ERAS, or must resort to printing out the files to take them home. Several suggestions have been made to copy the files to portable media such as Zip or Jaz drive cartridges. These suggestions have the disadvantages of requiring that one have a drive mounted on both computers, or carry the drive around with the media-both alternatives somewhat cumbersome and expensive ways of providing portability.

During the recent application season I have successfully used an alternative means of tranferring files from office to home. Although at first glance it might seem to be expensive, in the long run the cost is not a major factor, and is far outweighed by many advantages.

What I have done is to install ERAS on my laptop (which many, if not most, departments and directors already have available to them), and then download the newly received files on a daily basis from the desktop or network drive that serves as the main repository of the ERAS files. I have used a program called Laplink for Windows which works quite well, and downloads only the new files each time it is hooked up. The attachment between the two computers is through the two parallel ports using a special cable supplied with the software. Because the program adds only the new files each time, the process takes usually less than ten minutes per day.

The next step that I have used is then to link my laptop to my desktop at home (using the same software and cable) to take advantage of a regular monitor screen for reviewing the files. If you annotate the files, the changed files can be reloaded on the laptop very easily to keep all files current.

Almost any laptop sold today will have the processor (Pentium-or equivalent), speed, and hard disk size to accommodate the ERAS data set. The entire dataset this year occupied about 500MB on my laptop hard drive. An adequate laptop to fulfill these requirements costs under $1500 currently, with prices falling daily.

Furthermore, not only can one carry the entire ERAS data around and review it conveniently, you also have a fully functional computer to use for communications, document production, slide making and display, etc. So look at the ERAS application as free; it comes with the laptop you have, or need, for many other applications.

I would be happy to answer any questions about this process that programs might have. The set-up is quite easy and the daily maintenance is also quick and easy.

Albert Weihl, MD
Yale University

GME Workforce Committee Report

We have been considering a survey to determine the effect that HCFA's new regulation are having on our EM programs. Specifically we are interested in whether there have been further downsizing of programs since the ACEP Academic Affairs Committee survey looked into this issue in 1996 since much has changed since then. We hope to review this survey in Chicago and discuss the merit of another survey. We hope to explore not only downsizing of resident numbers that may be occurring but also how programs may be coping with the downsizing of funding that is occurring in many programs and how PGY IV years and combined programs will be funded in the future.

In addition, we would like to determine whether programs are able to consider applicants with prior training and how much prior training is too much. This issue is not only critical to all of our programs but also it is extremely important as we try to advise medical students about various strategies in pursuing emergency medicine.

Our task force will be considering several work force projections that have recently been proposed and how these will impact our specialty. We will also be considering other factors which may be influencing our workforce such as the explosion in urgent care centers and physician extenders.

Daniel Martin, MD
Ohio State University

Synopsis of the ACGME Strategic Initiative

Dr. David Leach, Executive Director ACGME, began the session by defining some of the initiative's goals. These goals for the future include shifting to outcomes assessment to guide the educational process and insure proficiency; identifying and defining general competencies for physicians; and developing an emphasis on institutional oversight of the educational process. Dr. Leach then provided a historical review of accreditation of medical education in the US (starting in 1914 with the first AMA Council of Medical Education and ending with the formation of the ACGME in 1981). He concluded that it is time to " preserve what is best and modify what isn't needed". Thus, the ACGME focus has shifted to examining competency and outcomes and encouraging innovative methods of facilitating this process.

In the past, providing the RRC with an established program of educational objectives and an organized curriculum to achieve those objectives was the sine qua non for accreditation. But what evidence did the programs or the ACGME have that they were really achieving their objectives? ACGME postulates that assessing outcomes will not only validate the educational process but will also improve it. As noted by Dr. Leach, "Anything we measure, we tend to improve". While process and structure measurements examine the potential to educate, outcomes measure if the program is actually educating. Outcome measurements will be more cost effective, allow programs more flexibility, and will provide for public accountability. Additional consequences of measuring outcomes include establishing a clear link between the process and the measurement; providing a formative assessment for both the program and the resident; and the ability to evaluate multidimensional levels of performance. Of course, a major part of the initiative is to establish which outcome measures are the best. Current measurement options include board exams, longitudinal measures of progress over time, OSCEs, 360 degree evaluations, chart stimulated reviews, oral exams, and CAARs (anonymous reviews sent directly to residents by the ACGME).

Currently the ACGME is examining a set of "General Competencies". These include medical knowledge, clinical skills, medical ethics, interpersonal skills, professionalism, CQI, medical informatics, and systems based practice. Dr. Leach concluded the meeting with a discussion of a "competency scale". The scale takes into account the concept that competency is governed by life long learning.