Council of Emergency Medicine Residency Directors

1998 National CPC Competition Finals

The National CPC Competition Finals were held on October 13 during the ACEP Scientific Assembly in San Diego. Resident presenters included Amy Hutson (Highland General), Michelle Bache (IU-Methodist), Samuel Connolly (University of Massachusetts), Allison Silver (Temple), and Sangita Rangala (Cook County). Faculty discussants included George Higgins (Maine Medical Center), Louis Durkin (Baystate Medical Center), Robert Gerhardt (Texas Tech), Pamela Ross (UVA) and David Chuirazzi (Allegheny General). As always, the case presentations and discussions were excellent. Many in attendance felt this may have been the best competition ever. After much deliberation and heartburn, the judges were able to select the winners. The Best Presenter Award went to Sangita Rangala and the Best Dicussant Award was presented to George Higgins. All the presenters and dicussants should be congratulated for their excellent participation. CORD would like to thank all the participants, the judges (Judith Brillman, Peggy Goodman, Andy Jagoda, and Kevin Rodgers), Rita Cydulka (National Coordinator), and Pat Miller (CORD office) for their contributions to this excellent event. The competition, which started in 1990, is sponsored by CORD, SAEM, EMRA, and ACEP.

The 1999 Regional CPC will be held May 19 in Boston, the day before the SAEM Annual Meeting. All programs are encouraged to submit a case for consideration. Invitation letters will be sent to all programs soon. For those interested in the history of the CPC, all recipients of the CPC Competition since the inception of the competition in 1991 are listed on the CORD web site .

1999 CPC Plans Begin

Terry Kowalenko, MD, has been selected by the CORD Board of Directors to serve as the National Coordinator of the 1999 CPC Competition. A CPC Task Force will be developed to coordinate the CPC Competition. Members of the Task Force will assist with the planning of the 1999 CPC Competitions, review and score submitted cases, and serve as judges and coordinators at the regional competition. If you are interested in serving on this year's CPC Task Force, please send a letter of interest to CORD (mail or e-mail at cord@cordem.org) by December 15, 1998.

President's Message

"ESPRIT DE CORPS"

We often refer to the "esprit de corps" when we consider resident enthusiasm regarding their training programs. Program directors generally have an idea of the "esprit de corps" of their programs and certainly applicants to residency programs are told by their advisors to look for it when they interview at programs. What is "esprit de corps"? According to one dictionary definition it is a spirit of enthusiastic devotedness to and support of the common goals of a group to which one belongs. The "esprit de corps" can be a sign of how well things are going.

I have had the good fortune to watch the "esprit de corps" grow amongst the residents at the relatively new emergency medicine residency program at the University of Virginia. In my opinion, "esprit de corps" is one measure of how well things are going overall, including opportunities for patient care/education, social interactions, interpersonal and general happiness. I hold biannual meetings with the residents and faculty to discuss rotational issues, departmental issues and any issues that have a bearing upon resident education and well being.

Sometimes the enthusiasm displayed by residents may be demonstrated by working together to host certain events such as Halloween or Christmas parties with attendance by other residents and clinical staff from the institution. Other times, the display may be through journal clubs organized by the chief residents and/or program directors. It may also be through such opportunities as dinner clubs, picnics, sporting events, outings or other channels. One commonality, however, tends to be the group dynamic and identification with emergency medicine. Sometimes the enthusiasm can be overwhelming for the program director and/or chairman. I would like to share with you an example of "esprit de corps" that caused more graying of my hair but had a pretty nifty outcome. I checked this out with the main characters in the episode in which I am about to describe and was granted permission without using their names to relay this story.

I was the attending on a 7-3 shift. Having just arrived for sign out, I witnessed the delivery of a bouquet of flowers to a senior female resident (hereafter referred to as SFR) by a senior male resident (hereafter referred to as SMR). According to the SMR, the flowers were delivered by a grateful patient. There was a little blue note attached to the flowers. Of course, continuing sign out rounds was difficult because everyone wanted to read the note. By this time, the SFR was blushing. I suggested that we call the local newspaper and have the note published so that everyone could read it and we could carry on with rounds. Subsequently, all the residents left to go to the half hour morning case conference. The SMR then informed me that the flowers were actually sent by the fiancee of the SFR but she didn't know that. He also informed me that in one half hour the flight crew would be bringing a patient in with a gunshot wound to the head. This was not a real patient, but would be the SFR's fiancee pretending to be injured and would take the opportunity during the chaos to propose marriage to the SFR. By this time my hair turned completely gray. I asked why I was not informed of this prior to now. The SMR indicated that he forgot to tell me. Really he didn't want to tell me because he realized that if I had known this much earlier that I probably would have cancelled the whole event. All I could think of was the dean, the president of the institution, the board of visitors and everybody else under the sun hearing about this resulting in the eventual demise of the EM residency program. After a few quick phone calls I was informed by staff that the helicopter was coming in on "PR" time and I need not worry about expense or other consequences.

Shortly after the SFR was called out of case conference to take a report on the "trauma alert" on a young male gun shot wound to the head. Considering the "esprit de corps", I found out the entire trauma team, including the Emergency Medicine resident members and much of the emergency medicine housestaff was aware of the fake patient. They were poised to come to this trauma alert as if it were real. The SFR took that call and being the senior resident on duty, was prepared to run the resuscitation and manage airway if needed. She positioned herself at the head of the bed. Five minutes prior to the trauma arrival, there were at least thirty people in the trauma room including the trauma director. One resident had a video camera and recorded the whole scene. The patient arrived not looking in much distress; however, the SFR was poised to resuscitate the patient. He jumped off the stretcher and got down on one knee. During this fell swoop of activity, the blood rushed entirely from the SFR's body to her feet. She instantly recognized the trauma victim and was frightened out of her wits. He then proposed marriage to her while on one knee. Everyone said, "well what do you say". She said, "I do". The whole department erupted in celebration including some nearby patients. I subsequently offered the SFR psychiatric evaluation but also offered my congratulations to her and her fiancee. The SMR arranged for coverage for the SFR during the day because he realized she would not be able to work the rest of the day.

Shortly afterwards the real trauma patients and cardiac arrests began to arrive and the department was back to business as usual. Someday the video may show up on the world's greatest home videos. The home in this case is the department of emergency medicine. After witnessing no complications, my hair returned to its normal color just sprinkled with a little gray. There was a happy ending here and certainly a huge display of "esprit de corps". It was a real joy to see residents stick together, work hard together and have fun together. However, I would not recommend this type of activity for your department. It is very nice to see the smiles on the residents faces when you work hard to provide the right atmosphere for their education and overall well being. Perhaps the greatest joy for program directors, other than the complete matriculation of the residents, is knowing that "all is well" and that there is enthusiasm about the residents' identity with their chosen careers of emergency medicine. I will let you know if the actual marriage is as exciting as the proposal. Meanwhile, stay tuned.

Happy Holidays. Good Luck with interviews.

Marcus Martin, MD
University of Virginia

Mark your calendars now for the 3rd annual faculty development course sponsored by CORD and AACEM. This conference is designed specifically for the unique needs of junior faculty and senior residents serious about a career in academic Emergency Medicine. Participants in previous courses have praised the practical topics discussed and the opportunities they had to network among colleagues. Please encourage and support appropriate faculty members from your institution to register for this conference.

"ERAS Tricks and Tips"

I presented a summary of ERAS "how-to's" at the recent CORD meeting in San Diego, and thought I'd try and put some of it down on paper to help facilitate incorporation into long-term memory (and for those of you who weren't with us in beautiful San Diego).

Q: How can I review files somewhere other than sitting at my desk at the main Program Director Workstation (PDW), or how can multiple people review files at once?

A: You can avoid all of the following by using remote access software and dialing in to your main PDW or office/hospital LAN to work remotely. If this is not possible, read on...

The good news is that ERAS has made it much easier to take files home for review via the "HOME COPY"feature. The bad news is that it is not possible to alter or otherwise manipulate the data in the HOME COPY satellite version. But you can take hand-written notes, and then get someone else (secretary) to input your comments into your main PDW. If you are about to invest in some hardware to make this possible, I would recommend a JAZZ or Syquest drive over a ZIP drive at this point because they hold more per disk, but you can do it with the ZIP.

To make a new HOME COPY:

1. Make sure you are in the Applications Window.
2. Use a FILTER/SORT to bring up the group of applicants that you want to take with you as a home copy. (See below for using FILTER/SORT)
3. Select HOME COPY from the EDIT menu.
4. Click on the button that says ALL APPLICANTS IN RECORD SET
5. The default destination directory is D:\ERASSERV.99S. If your ZIP/JAZZ drive is a different letter than D, change the D to the appropriate letter.
6. Click OK
7. Click YES to a printed copy, which will give you a very useful list of the applicants you just copied for note taking and record keeping.

To use your HOME COPY:

1. Put the ZIP/JAZZ disk in your other computer's drive.
2. Open up the ERASAERV.99S file.
3. Open up the PDW icon, and go through the INSTALL instructions.

Q: How do I use the FILTER/SORT function to pare-down the applicant field into a subset that I am interested in viewing (or copying) now?

A: Let's say you want to view all applicants that you have rejected. To do this, you would have to have been clicking off "INACTIVE" on the Summary Sheet page as you decide to reject each applicant.

1. Select FILTER/SORT from the FILE menu.
2. Scroll down the list until you find "Inactive applicants sorted alphabetically," and then click on it.
3. Click on OK.

1. Click on Filter/Sort from the File menu.
2. Click on NEW
3. Give your new F/S a name, ie. UCLA
4. The FIELD box will give you a drop-down menu of variables to select from. Choose MEDICAL SCHOOL for this example.
5. The VALUE box will give you a drop-down menu of all medical schools. Scroll down to University of California, Los Angeles.
6. Click on ADD TO CRITERIA
7. Click on the appropriate box to Exclude not selected and/or exclude withdrawn applicants from the record set, depending on what you want.
8. Click OK when finished.

1. Select FILTER/SORT from the FILE menu.
2. Click on NEW
3. Type in a name for this new filter/sort, ie. A to H
4. Click in the FIELD box and select "LastName"
5. Make sure the Operator is "<="
6. Click in the Value box and select "H*" -- don't forget the asterik
7. Click "Add to criterion"
8. Click OK

Let's say you want to create a new F/S with more than one variable, like selected to interview and without 3 letters of recommendation, sorted alphabetically. You can do this using the Filter/Sort Combined Wizard.

1. Select F/S from the FILE menu.
2. Click on Combine Wizard
3. Highlight the Filter called "Selected to Interview applicants, sorted alphabetically," and click NEXT
4. Highlight the Filter called "Applicants with less than 3 letters, sorted alpha," and click AND.
5. Click on NEXT
6. Enter a title for your new F/S and click FINISH.

A: You aren't supposed to be able to do this because the USMLE people don't want us to only look at the score we are supposed to have to read how many times the applicant took each part of the boards, if there were any special circumstances, etc. Yeah, yeah, yeah, whatever...

1. Go to the Documents page.
2. Open someone's USMLE transcript.
3. Use the VCR buttons (the <<>> the left of the screen) to advance through the whole record set in a few seconds. You have now opened everyone's USMLE transcript without really trying, and the scores will now show up on the Scores and Comments page.

Although the ERAS Task Force has been dissolved, I will continue to provide the CORD membership with new information about ERAS as it becomes available. I invite you to continue to direct any comments and suggestions you have about ERAS to me, and I will continue to provide feedback to the AAMC.

Pam Dyne, MD
UCLA/Olive View-UCLA

Procedural Competency Task Force Report

The CORD Procedural Competency Task Force (PCTF), is attempting to wrap up all of its activities within the next year. The status of each of those activities is as follows:

1. Survey of EM residency programs regarding current resident procedural experience. This project has been completed. The manuscript has been completed and reviewed by the PCTF and the CORD board. It has now been submitted to AEM for publication.

2. A second article, "Es tablishing Procedural Competency for Residents: Lessons Learned from Other Specialties," is meant to summarize some of the experiences and lessons learned by the PCTF, in the course of tackling this project. It has been outlined, with the goal of manuscript submission within the year.

3. Procedure Compete ncy Evaluation Form. Th e PCTF has drafted up a model form that would be use d as the structure o f establishing procedural competency checklists for each of the major pr ocedures. It has been approved by the PCTF leadership, and the CORD board. It involves three parts. The first page addresses cognitive aspects of a procedure; the second page actual psychomotor performance; the third page is a set of instructions to guide faculty or other preceptors, in performing the evaluation, or in accessing acceptable levels of cognitive knowledge. This format will then be applied to establishing actual forms for each of the major procedures that EM residencies are required to track and report, for the RRC. By all indications, evaluation forms such as these are not currently in existence in other specialty residencies and may be relatively unique. The format of the forms will be (was) presented and discussed at the CORD meeting in October. We are still looking for volunteers for assignments to complete the details of these forms for individual procedures. Please contact Dr. Panacek directly for further information.

Ed Panacek, MD
University of California, Davis

Roundtable Discussion: RRC Accreditation Issues

During the CORD Meeting in San Diego on October 12, several topics were discussed at the roundtable session led by Residency Review Committee (RRC) for Emergency Medicine members Connie Greene, Debra Perina, Jo Linden, and Larry Sulton. The first inquiry of the group was in reference to the documentation about the curriculum, which was required in the program information form (PIF). Previously a checklist of the core content was included. This list is no longer a part of the PIF, but the information must still be available in some form for the site surveyor to review. Most programs now have their own computer data systems for recording how all aspects of the curriculum will be covered--this is an ideal means of documentation for the RRC as well.

A question was asked regarding what influences the RRC to make changes in the requirements. Examples given included changing the official definition of resuscitation and deleting certain procedures that are becoming obsolete, such as culdocentesis. It was pointed out that, since the RRC is composed of currently practicing emergency physicians, the committee has often discussed these changes. In addition, before every major revision in the program information form the RRC solicits input from all residency directors about their suggestions for improvement. The next revision of the PIF is anticipated to be completed in the year 2000.

The topic that raised the most concern, scholarly activity, has been the area with the most numerous citations to programs from the RRC. It was clear that core faculty must participate in scholarly activity and must have protected time from clinical activities to do so. One cannot regularly be scheduled to do 40 hours per week clinical work and have adequate time for scholarly pursuits. The gold standard measure of scholarly activity is original research presented in a peer-reviewed publication. Not only must original research be conducted, but the residents must have the opportunity to participate. Other endeavors, such as developing a unique curriculum, initiating a patient education program or lecturing in an area of specialty for regional or national audiences might be considered scholarly activities as well. All members of the faculty do not have to be "researchers" per se, but if only one or two attending physicians do research, there will not be enough projects available for all residents to participate. Thus, the environment of the residency must be one of overall academic productivity. The real questions that a program director should address are how do you exhibit academic activity in your program and are the residents given enough opportunity and choice for their involvement?

There was some discussion about the faculty development plan needed for each core faculty member. The RRC members present indicated that this plan is intended to be a description of the goals each faculty member has for his/her own career training and enhancement. It is not a job description (e.g., required to give four lectures per year, participate in candidate interviews and do 12 shifts per month).

The last topic touched upon by the group was the need for the program director to have some authority over faculty hiring and development. This was not intended to be used by the program director to usurp the responsibilities of the department chair. However, program directors must have input into decisions about faculty members, particularly with issues involving the residents and their training.

The final message from the RRC members to the group was that any one citation or lack of adequate numbers in one specific procedure generally does not cause a program to lose accreditation. They are not interested in micromanaging each program. The RRC looks at the "snapshot" of the residency as a whole, as provided by the PIF, and at the site survey to assess the adequacy of the residents training in a particular EM residency program.

Mary Jo Wagner, MD
Saginaw Cooperative Hospitals, Inc.

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