Additional studies are needed to determine whether these results are sustainable and generalizable to other residency programs in emergency medicine and other specialties.

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Instructions to trust one's first impres-sions result in similar performance when compared with instructions to consider clinical information in a systematic fashion, but have greater utility when used for the purposes of assessment.

As the emergency department (ED) is the "front door" of the hospital and the primary site by which most patients access the health care system, issues of inequity are especially salient for emergency medicine (EM) practice. Improving the health of ED patients, especially those who are stigmatized and disenfranchised, depends on having emergency physicians that are cognizant and attentive to their needs in and out of the medical encounter. EM resident education has traditionally incorporated a "cultural competency" model to equip residents with tools to combat individual bias and stigma. Although this framework has been influential in drawing attention to health inequities, it has also been criticized for its potential to efface differences within groups (such as socioeconomic differences), overstate cultural or racial differences, and unintentionally reinforce stereotypes or blaming of patients for their ill health or difficult circumstances. In contrast, emerging frameworks of structural competency call for physicians to recognize the ways in which health outcomes are influenced by complex, interrelated structural forces (e.g., poverty, racism, gender discrimination, immigration policy) and to attend to these causes of poor health. We present here the framework of structural competency, extending it to the unique ED setting. We provide tangible illustrations of the ways in which this framework is relevant to the ED setting and can be incorporated in EM education.From the

IntroductionThis study examines the emergency department (ED) waiting room (WR) population’s knowledge about the ED process and hospital function and explores the types of educational materials that might appeal to patients and their companions in an ED waiting room. Our goal was to identify potential high-impact opportunities for patient education.MethodsA 32-question survey about demographics, usage of primary care physicians (PCP), understanding of the ED and triage process, desire to know about delays, health education and understanding of teaching hospitals was offered to all qualified individuals.ResultsFive hundred and forty-four surveys were returned. Fifty-five percent reported having a PCP, of which 53% (29% of all WR patients) called a PCP prior to coming to the ED. It was found that 51.2% can define triage; 51% as an acuity assessment and 17% as a vital signs check. Sixty-nine percent knew why patients were seen according to triage priority. Seventy-two percent wanted to know about delays, yet only 25% wanted to know others’ wait times. People wanted updates every 41 minutes and only three percent wanted a physician to do this. Forty-one percent wanted information on how the ED functions, 60% via handouts and 43% via video. Information on updates and common medical emergencies is significantly more important than material on common illnesses, finding a PCP, or ED function (p<0.05). Median estimated time for medical workup ranged from 35 minutes for radiographs, to one hour for lab results, computed tomography, specialist consult, and admission. Sixty-nine percent knew the definition of a teaching hospital and of those, 87% knew they were at a teaching hospital. Subgroup analysis between racial groups showed significantly reduced knowledge of the definitions of triage and teaching hospitals and significantly increased desire for information on ED function in minority groups (p<0.05).ConclusionThe major findings in this study were that many visitors would like handouts about ED function and medical emergencies over other topics. Additionally, the knowledge of functions such as triage and teaching hospitals were 70% and 69%, respectively. This was reduced in non-Caucasian ethnicities, while there was an increased desire for information on ED function relative to Caucasians. This research suggests increasing updates and educational materials in the waiting room could impact the waiting room and overall hospital experience.

Introduction Recruiting and retaining residents who will complete their emergency medicine (EM) training is vital, not only because residency positions are a limited and costly resource, but also to prevent the significant disruptions, increased workload, and low morale that may arise when a resident prematurely leaves a program. We investigated national rates of EM resident attrition and examined the reasons and factors associated with their attrition. Methods In this retrospective, observational study we used national data from the American Medical Association National Graduate Medical Education Census for all residents who entered Accreditation Council for Graduate Medical Education-accredited EM programs between academic years 2006–2007 and 2015–2016. Our main outcome was the annual national rate of EM resident attrition. Secondary outcomes included the main reason for attrition as well as resident factors associated with attrition. Results Compared to the other 10 largest specialties, EM had the lowest rate of attrition (0.8%, 95% confidence interval [CI] [0.7–0.9]), or approximately 51.6 (95% CI [44.7–58.5]) residents per year. In the attrition population, 44.2% of the residents were women, a significantly higher proportion when compared to the proportion of female EM residents overall (38.8%, p=0.011). A greater proportion of Hispanic/Latino (1.8%) residents also left their programs when compared to their White (0.9%) counterparts (p<0.001). In examining reasons for attrition as reported by the program director, female residents were significantly more likely than male residents to leave due to “health/family reasons” (21.5% vs 9.6%, p=0.019). Conclusion While the overall rate of attrition among EM residents is low, women and some under-represented minorities in medicine had a higher than expected rate of attrition. Future studies that qualitatively investigate the factors contributing to greater attrition among female and some ethnic minority residents are necessary to inform efforts promoting inclusion and diversity within the specialty.

Introduction: Expanding on data concerning emergency department (ED) use and avoidance by the sexual minority (those who identify as lesbian, gay, bisexual, queer, other [LGTBQ+]) and gender minority (those who identify as transgender, gender nonconforming, other) community may inform future ED LGTBQ+ training and clinical practice. Investigation objectives included characterizing rates of emergency care avoidance, identifying barriers to emergency care, and assessing emergency care quality and cultural competency for sexual and gender minorities. Methods: In this population-based, cross-sectional needs assessment, sexual minority, gender minority, and/or cisgender heterosexual-identified participants were selected based on participants’ subscription to newsletters or social media accounts for One Colorado, an LGBTQ+ advocacy organization. Each participant completed a single digital survey that collected qualitative and quantitative data about ED perception, use, and demographics. Results: A total of 477 LGBTQ+ or heterosexual-identified individuals (mean age = 44.3 (standard deviation [SD] = 16.7)) participated in the study. Lifetime emergency care avoidance rates for gender minorities were markedly increased (odds ratio [OR] 3.8, 95% confidence interval [CI], 2.2 – 6.6; P <.001), while avoidance rates for sexual minorities were similar to those of cisgender heterosexual respondents (17% vs 14%; P <.001). Gender minorities were more likely than sexual minorities to both avoid emergency care due to fear of discrimination (43% vs 15%; P =.002) and to have experienced discrimination during their last ED visit (OR 11, [95% CI, 5–24]; P <.001). No significant differences were observed between participants in care avoidance due to financial reasons or prior negative experiences. No cited ED factors that influenced identity disclosure decisions were distinctly predictive. Conclusion: Gender minorities are more likely than sexual minorities and heterosexual cisgender individuals to report ED avoidance and discrimination at last ED visit. Future work characterizing deficits in LGBTQ+ ED care might reduce these avoidance and discrimination rates, enhancing the level of patient care provided to this population.

Purpose This study examined applicant reactions to the Association of American Medical Colleges Standardized Video Interview (SVI) during its first year of operational use in emergency medicine (EM) residency program selection to identify strategies to improve applicants’ SVI experience and attitudes. Method Individuals who self-classified as EM applicants applying in the Electronic Residency Application Service 2018 cycle and who completed the SVI in summer 2017 were invited to participate in 2 surveys. Survey 1, which focused on procedural issues, was administered immediately after SVI completion. Survey 2, which focused on applicants’ SVI experience, was administered in fall 2017, after SVI scores were released. Results The response rates for surveys 1 and 2 were 82.3% (2,906/3,532) and 58.7% (2,074/3,532), respectively. Applicant reactions varied by aspect of the SVI studied and their SVI total scores. Most applicants were satisfied with most procedural aspects of the SVI, but most applicants were not satisfied with the SVI overall or with their total SVI scores. About 20% to 30% of applicants had neutral opinions about most aspects of the SVI. Negative reactions to the SVI were stronger for applicants who scored lower on the SVI. Conclusions Applicants had generally negative reactions to the SVI. Most were skeptical of its ability to assess the target competencies and its potential to add value to the selection process. Applicant acceptance and appreciation of the SVI will be critical to the SVI’s acceptance by the graduate medical education community.