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GRACE Recurrent, Low-risk Chest Pain: A User’s Guide
Recurrent, Low-risk Chest Pain: A User’s Guide
By D. Mark Courtney, MD, MSc and Eddy Lang, MD
The July 2021 issue of Academic Emergency Medicine (AEM) contains two articles (Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department and Navigating Uncertainty with GRACE) that are at the same time a culmination of a multiyear effort but also the first early steps of the journal and the Society for Academic Emergency Medicine (SAEM) leadership into the science of practice guideline creation and dissemination. It is anticipated that readers could raise three basic questions about this endeavor: (1) What is the rationale for this effort and how is it unique relative to what has been done to date? (2) What can I take to the bedside regarding chest pain? and (3) What can we learn from this first effort — to provide evidence-based guidance for undifferentiated repeat chest pain — that might inform future guidelines on other topics?
What is the Rationale for this Effort?
Emergency physicians have a love–hate relationship with clinical practice guidelines. On one end of the spectrum, guidelines in cardiopulmonary resuscitation have been at the heart of our specialty's development guiding practice and training for nearly 30 years. These guidelines developed through the International Liaison Committee on Resuscitation (ILCOR) and adopted by seven resuscitation councils around the world are widely implemented across emergency care and CPR education systems with each update eagerly awaited by millions of end-users. On the other end of the spectrum, guideline recommendations on thrombolytic therapy for acute stroke within a 3- to 4.5-hour window has raised the ire of many emergency physicians, resulted in deep examination and debate of source research studies, and resulted in iterative modification of initial recommendations. Moreover, guidelines may not result in practice change, as suggested by an analysis of syncope care, including neuroimaging
and hospitalization rates before versus after guideline publication. This varied life trajectory of guidelines may be due to several factors, but chief among these may be varying perceptions of what constitutes a “trustworthy guideline.”
In its landmark 2013 report the then Institute of Medicine defined clinical practice guidelines as “statements that include recommendations that are intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” The report's title, “Clinical Practice Guidelines We Can Trust,” spoke volumes to the general state of guideline development and impact at the time. While problems identified were wide-ranging, key recommendations emphasized the importance of a systematic review supporting the guideline and emphasis on an explicit and transparent processes to make clear how recommendations were determined and that the process was conducted in an unbiased manner as much as possible. Description of this process has become known as GRADE (Grading of Recommendations Assessment, Development and Evaluation).
With this GRADE process as the current benchmark for guideline creation, the article by Musey et al. describes the laborious tasks undertaken by an expert group to arrive at a guideline for emergency clinicians in the care of recurrent low-risk chest pain. This is a much different question and process than prior guidelines. The authors address an undifferentiated symptom rather than the evaluation of “non-ST elevation coronary syndrome.” The focus is on recurrent low-risk chest pain, acknowledging that a significant proportion of who we see in the emergency department (ED) are recurrent visits for chest pain defined here as patients who have had a previous visit to an ED with chest pain in the past 12 months that led to a diagnostic protocol for evaluation but did not demonstrate acute coronary syndrome (ACS) or flow-limiting coronary stenosis. This is a common, but previously unaddressed, scenario that readers will not find addressed in any cardiology, general medical, or emergency medicine textbook—hardcover or online. There are several further methodological reasons why this GRADE approach applied to chest pain is unique relative to prior work, state of the art, and potentially likely to impact care.
First, the GRACE approach, which is Academic Emergency Medicine's (AEM) term for this guideline effort (Guidelines for Reasonable and Appropriate Care in the ED) fulfilled the systematic review criteria, adhering to current standards for the conduct and reporting of this category of scientific literature. Second, in keeping with GRADE guidance, outcomes of interest were selected and prioritized for importance and impact on the final seven recommendations. This recognizes that not all outcomes are created equal and thus may not carry the same value for patients. The GRADE approach being outcome-centric characterizes the certainty in evidence for each outcome across studies as would be standard in a systematic review. Third, GRADE deviates from most other guideline frameworks by not relying on study design alone to drive the evaluation of evidence. Typically, this plays out with the strongest category of recommendation invoked if randomized controlled trials (RCTs) exist to inform a question. GRADE takes a more critical approach, as we do in our journal clubs, applying standardized, reproducible assessments of evidence certainty so that even RCTs may land in the lowest category thus unlikely to support strong recommendations. Similarly, non-RCTs with compelling effect sizes that are at low risk of bias due to confounding can rise to the high-certainty category and drive a strong recommendation.
What Can We Take to the Bedside?
Low-risk chest pain in this guideline will be most typically defined by clinicians as a HEART score of <4 (history, EKG, age, risk factors, and troponin) in the context of a non-concerning (electrocardiogram) ECG. This is very common among patients who have had a prior unremarkable ED evaluation with testing unrevealing of ACS or flowlimiting stenosis in the prior 12 months, which meets this guideline's definition of “recurrent.” There are some caveats important for clinicians to consider prior to implementation. (1) These definitions of low risk and recurrent; (2) importance of evaluating an initial ECG; and (3) diligent review of the electronic medical records and patient's history as to prior ED visits, testing, and outcome of that testing.
The highest level of evidence supports what is still an uncommon scenario: prior coronary computed tomographic angiography with no stenosis may be considered for no further testing after a single high-sensitivity troponin. Low certainty in evidence was noted for much of the other recommendations thus deemed conditional, including cases of recurrent low risk chest pain of >3-hour duration where a single negative high-sensitivity troponin may reasonably exclude ACS within the subsequent 30 days. Also importantly, in patients with recurrent low-risk chest pain and a normal stress test in the prior 12 months, it is not recommended to employ routine further stress testing to reduce subsequent 30-day major adverse cardiac events (MACE). In our opinion the other important statement is that there is insufficient evidence to recommend hospitalization (either inpatient admission or observation) versus discharge as a strategy to mitigate 30-day MACE. Further recommendations including screening and referral for anxiety and
depression, previously unexplored topics in the context of chest pain, should also be noted in this novel work. Table 1 of the GRACE guidelines make clear that conditional recommendations, while usually directional that is, for or against, are ideally suited to a personalized approach with patients that sees key decisions driven by their own values and preferences.
What Can We Learn From This First Effort to Provide Evidence-Based Guidance for Undifferentiated Repeat Chest Pain That Might Inform Future AEM GRACE Guidelines?
While AEM's GRACE effort is a laudable and important first foray into GRADEbased guidelines with tremendous potential for future endeavors, some improvements can still be attained. These include a more transparent, structured, and prioritized process for guideline topic selection. Also important is the ability to engage educated and trained patients more constructively into the relevant components of the guideline development process and to do so in a manner that optimally reflects the heterogeneity of patients seeking care and the optimal goal of delivery of care in an equitable manner.
An essential GRADE feature that merits emphasis in future GRACE iterations is the evidence-to-decision framework. This approach explicitly laid out in formatted tables of this manuscript's electronic supplemental content encourages consideration of a wide range of relevant factors. These items include the balance between the overall benefits and harms of a given approach, an assessment of patient values and preferences either known or supposed, equity and resource considerations, and acceptability and feasibility. GRACE holds the promise, therefore, of rendering care more rational, efficient, and cost-effective; reducing the harms of over-testing and referral; and preserving health care resources for those in need.
At the end of the day, the worst fate that can come to a clinical practice guideline is to have it gather virtual dust on the journal's server as an academic exercise, unknown and unused by the desired end-users. Multistakeholder engagement by organizations and societies that can see the merit of the GRACE recommendations and be willing to serve as avenues for endorsement and dissemination could be critical. This step can catapult these recommendations into decision support within electronic health records and implementation for millions of chest pain visits across the United States and beyond transforming these recommendations into shared decision making with patients at the point of care.
What Is GRACE and Why Low-Risk Chest Pain?
SAEM’s Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE) emerged to address the critical need for evidence-based and expert-driven, trustworthy, and transparent recommendations for the clinical care of common chief complaints and syndromes, prioritizing those with demonstrable practice variability and significant malpractice angst that often elicit decisional conflict or treatment uncertainty. To accommodate meaningful recommendations for questions that reside at the intersection of evidence and clinical expertise, GRACE uses the widely adopted Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework to facilitate transparency in weighing the strength of evidence balanced against pragmatic constructs of health equity, potential harms, and costs. The first publication in the GRACE series focuses on low-risk chest pain, titled "Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE Recurrent, Low-risk Chest Pain in the Emergency Department." Chest pain is the second most common chief complaint in the emergency department (ED), with only five percent of patients diagnosed with an acute, life-threatening condition. There are significant physician and institutional variations in diagnostic testing and admission of these patients, creating a need for clinical practice guidelines to aid in the evaluation and treatment specific to the ED population. See also: GRACE-1 Recurrent Low-Risk Chest Pain in the ED Recommendations
GRACE-1: Recurrent, Low-Risk Chest Pain in the ED
RECURRENT CHEST PAIN: Defined as patients who have had a previous visit to an emergency department (ED) with chest pain that led to a diagnostic protocol for its evaluation that did not demonstrate evidence of acute coronary syndrome or flow-limiting coronary stenosis. This included two or more ED visits for chest pain in a 12-month period. LOW RISK: Low risk was defined by HEART score <4 points (and other scores validated in the ED setting such as the HEART pathway or TIMI score) for disease-related poor outcomes within 30 days, all of which require an electrocardiogram (ECG) for risk stratification.
PICO QUESTIONS
1(P) In adult patients with recurrent, low-risk chest pain, (I) is a single troponin vs (C) serial troponins needed for (O) ACS outcomes within 30 days?
2
(P) In adult patients with recurrent, low-risk chest pain, and normal or non-diagnostic stress testing within the last 12 months, (I) does repeat stress testing vs (C) no stress test have an effect on (O) MACE within 30 days?
3 4
(P) In adult patients with recurrent, low-risk chest pain, is (I) admission to the hospital versus (C) stay in the ED observation unit versus (C) outpatient follow up recommended for (O) ACS outcomes within 30 days?
5
6(P) In adult patients with recurrent, low-risk chest pain and a negative coronary CT angiogram (E) what is their risk of subsequent ACS and time to ACS?
7(P) In adult patients with recurrent, low-risk chest pain, (I) what is the yield of depression and anxiety screening tools in (O) healthcare use and return ED visits?
8(P) In adult patients with recurrent, low-risk chest pain, (I) what is the role of referral for anxiety/depression in (O) healthcare use and return ED visits?
RECOMMENDATIONS
1In adult patients with recurrent, low-risk chest pain, for greater than 3 hours duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude ACS within 30 days. (Conditional, For) [Low level of evidence]
2 3 4 5 6
In adult patients with recurrent, low-risk chest pain, and a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of MACE at 30 days. (Conditional, Against) [Low level of evidence] In adult patients with recurrent, low-risk chest pain, there is insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days. (No evidence, Either) In adult patients with recurrent, low-risk chest pain and non-obstructive (< 50% stenosis) CAD on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation. (Conditional, For) [Low level of evidence] In adult patients with recurrent, low-risk chest pain and no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation. (Conditional, For) [Low level of evidence] In adult patients with recurrent, low-risk chest pain and prior CCTA within the past two years with no coronary stenosis, we suggest no further diagnostic testing other than a single, high-sensitivity troponin below a validated threshold to exclude ACS within that two-year time frame. (Conditional, For) [Moderate level of evidence]
7In adult patients with recurrent, low-risk chest pain, we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return ED visits. (Conditional, Either) [Very low level of evidence]
8In adult patients with recurrent, low-risk chest pain, we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits. (Conditional, Either) [Low level of evidence]
The New Frontier in Academic Emergency Medicine: A Tale of Two EDs
By Nicholas Stark, MD; William Baker, MD; Zaid Altawil, MD; Stephanie Stapleton, MD; and Christopher Peabody, MD, MPH on behalf of SAEM’s ED Administration and Clinical Operations Committee
Adjusting to constant change and thriving amid limited resources is the bedrock of emergency medicine (EM). While EM physicians are experts in making rapid decisions and adjusting them based on new information in the clinical environment, emergency department (ED) systems are often much less agile. The unprecedented challenges presented by the COVID-19 pandemic highlighted weaknesses in these existing systems, whether in the realm of disrupted supply chains for personal protective equipment (PPE), weakened physical infrastructure, or interrupted clinical communication platforms. These challenges created a profound sense of urgency that catalyzed a new wave of innovation across the field that continues to grow. This article highlights innovations developed by two large academic EDs in response to the COVID-19 pandemic and explores the potential for incorporating innovation into the academic EM environment. Innovation (i.e., the creation, development and implementation of a new product or process with the aim of improving a system or creating new value) has become increasingly vital in health care. Innovation within EM — especially at large, academic centers — is often challenged by complex problems involving multiple systems and stakeholders. Work toward change is traditionally focused on discovering convergent solutions for these oftendivergent problems, where flexible, multi-element solutions that can quickly evolve may be both timelier and have greater impact. Two academic EDs — Boston University affiliated Boston Medical Center (BMC) and the University of California San Francisco affiliated S.F. General Hospital (SFGH) — worked to transform weaknesses exposed by the COVID-19 pandemic into meaningful opportunities for rapid-cycle innovation in large academic settings. By utilizing key principles of engaging stakeholders, design thinking, rapidcycle optimization, and working closely
with department and hospital leadership, their experiences serve as beacons for others working to incorporate innovation into the academic EM environment.
BMC’s experience highlights many of the product-based innovations rising to the forefront of EM. For example, when BMC experienced a severe shortage of PPE due to disrupted supply chains, their team of clinical innovators quickly assembled a coalition of manufacturers to develop new modalities for sourcing and creating PPE, created a workflow for vetting PPE donations, and sourced expertise to replace out-of-stock parts with 3D-printed analogues. Their team partnered with MIT Project Manus and the MIT Center for Bits and Atoms in developing and testing face shields, and also worked with teams at MIT to develop an advanced display for the aging LTV-1200 ventilator. Other collaborative projects included the development of intubation hoods and HEPA filtered negative pressure enclosures for intubation and aerosolizing procedures. These collaborations involved BMC serving both as a subject matter expert and as a platform for iterative product testing. This process was the subject of BMC’s presentation at Global Response to COVID-19 (timestamp 38:43) FabXLive 2020.
While SFGH experienced many of the same product-related challenges early in the COVID-19 pandemic, their innovation team recognized an even more pressing issue for their ED: access to rapidly changing clinical protocols and information. Using a designthinking approach, their team ultimately replaced a disparate array of daily emails and online folders with a centralized, standardized digital platform. This physician-led open access platform (E*Drive) is accessible on any device with an internet connection, is able to be updated multiple times per day, and has since evolved to encompass all types of clinical information from clinical guidelines to discharge resources. These homegrown solutions to democratizing clinical information involved close collaboration with both leadership and end-users to rapidly develop digital tools that can evolve as needs change.
BMC and SFGH EM physiciandriven innovations were successfully implemented during the COVID-19 pandemic. These groups represent a small fraction of the EM grassroots innovation that has been ubiquitous throughout the pandemic. Even prior to the COVID-19 pandemic, we EM physicians prided ourselves with our “MacGyver” spirit: we can find solutions to anything! Our field is hallmarked by an ability to adapt to constant change, and we have the potential to not only drive innovative change within academic EM during a pandemic, but within health care.
ABOUT THE AUTHORS
Dr. Stark is chief resident and assistant director of the Acute Care Innovation Center, University of California San Francisco, department of emergency medicine. @NickStarkMD
Dr. Baker is senior vice chair and clinical associate professor, Boston Medical Center, department of emergency medicine. @EMDocBaker
Dr. Altawil is adjunct assistant professor of emergency medicine, Boston Medical Center, Department of Emergency Medicine. @zaidaltawil
Dr. Stapleton is director of emergency medicine simulation and assistant professor of emergency medicine, Boston University School of Medicine.
Dr. Peabody is director of quality and performance improvement and director of the Acute Care Innovation Center, University of California San Francisco, department of emergency medicine. @ToffPeabody
“All in the Family”: A Unique Mentorship Structure for ARMED MedEd
By Wendy C. Coates, MD and Lalena M. Yarris, MD, MCR, ARMED MedEd Co-Chairs on behalf of the ARMED MedEd Steering Committee
In February 2021, a talented and enthusiastic cadre of emerging leaders in health professions education research logged into “another Zoom session” to meet one other and the experts who would be serving as course faculty and their personal mentors. There was palpable excitement on the screen to begin the inaugural ARMED MedEd course (Advanced Research Methodology, Evaluation, Design for Medical Education). The 21 participants range from fellows to department chairs and share an interest in creating a collaborative network of rigorously trained health professions education researchers within SAEM. Each will write a grant proposal and conduct a multi-institutional study with faculty mentorship through our innovative structure, culminating with a research fair where they’ll present their work followed by a graduation celebration at SAEM22.
Mentorship is widely valued as an integral component of personal fulfillment and career success. The concept of modern mentorship arose in both the business world and in K-12 education. Benefits extend beyond the obvious mentee target to include mentors and organizations whose leaders make it a strategic priority and cultivate a culture of mentorship. Mentorship based on race and/or gender in academics and biomedical research has positive impacts on productivity, career advancement, and research funding. The resulting community of professional networks facilitates scholarly productivity and career satisfaction. In designing ARMED MedEd, a task force of experts recognized the need to create a successful environment for researchers that focused on three pillars of success: knowledge, mentorship,
“The family structure is awesome. My ‘family’ provides experienced perspectives from amazing researchers around the country (and Canada!) who help shape and refine my project and keep things on track.” — Ben Schnapp, MD, MEd, ARMED MedEd Participant
Figure 1: ARMED MedEd Mentorship Family Structure. Each family consists of three participant/mentor dyads and a senior mentor, methodologist, subject experts, and one mentor who is a member of the ARMED MedEd Steering Committee, to ensure sharing of best practices.
and collaborative networks. In order to build a strong knowledge base, ARMED MedEd holds monthly seminars via Zoom that highlight important topics in health professions education research. The program also features in-person meetings, beginning with a two-day launch at SAEM headquarters in Chicago and daylong workshops at the SAEM and ACEP annual meetings. Recognizing the importance of mentorship and networks, and with the aim of creating a diverse training program that promotes equity in education research, ARMED MedEd was envisioned as a health professions education community of practice with a nested intentional mentorship program. We describe the innovation and development of this mentorship structure implemented to promote a sense of community and support scholars in grant writing and completing a collaborative education research project.
Historically, research in the educational domain has been criticized for lack of generalizability since many studies occur in a single institution. Individuals may require additional mentorship beyond what a single mentor may provide and to develop the future pool of mentors, novices require guided experience in mentoring.
To address these needs, we created the “ARMED MedEd Family Mentorship Program” to provide a multilayered mentoring structure that fosters
Figure 2: A mentor family meeting (representing California, Massachusetts, New York, Ontario, Pennsylvania, Wisconsin) to discuss the development of three unique research projects: (1) identifying real-time interventions to mitigate gender disparities in narrative comments to EM trainees; (2) resident dashboards to mitigate differences in clinical exposure; (3) Debrief it all: Inclusion of Safety-II in health care debriefing
“The ARMED MedEd mentor family experience personalizes what it means to be part of a community of practice. I cannot think of a better way to share my expertise and foster the next generation of medical education
researchers.” — Stefanie Sebok-Syer, PhD, ARMED MedEd methodology mentor
MEDICAL EDUCATION
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mentorship from peers, content experts, methodologists, and senior career mentors with research expertise (Figure 1). Each participant is paired with an individual mentor to form a dyad. The two are in close contact about the research project (and grant proposal) and address challenges that are important to academic researchers. Groups of three dyads comprise a family, along with a senior mentor who serves to advise and participate in discussions but is not a part of a dyad.
Individual dyads and families meet on a regular basis. A list of suggested topics for discussion is provided to guide these discussions, but we expect that most meetings will address issues that arise throughout the course in an organic way. Individual dyad meetings focus on one-on-one mentoring, and mentor families meet monthly via Zoom to present their project progress to the rest of the family members. (Figure 2) All family members participate substantially in refining the study designs and provide support to the principal investigators. In this way, each participant may benefit from the mentorship of the methodologist (PhD and/or MD/DO), content experts (e.g., assessment, curriculum development, diversity, faculty development, simulation, ultrasound, etc.) and senior mentor of the family. At the same time, the remaining two participants are guided in serving as peer mentors and eventual coinvestigators on each other’s projects, thus facilitating three multi-institutional studies for each family. We hope this will lay the foundation for a broad network of collaborators in the future and foster meaningful professional relationships
“ARMED MedEd has been a fantastic learning experience and offers unique and innovative mentoring and collaboration through its use of mentor families. The course provides the advanced framework necessary for MedEd research and has offered an unprecedented opportunity to learn, be mentored by, and collaborate with many of the wisest, biggest names in medical education research. The mentor families provide not just a single mentor but multiple with strategically varied areas of expertise coupled with the chance to learn with two other ARMED MedEd scholars.”
“The mentor family structure provides the framework, resources, and support to successfully conceptualize and implement innovate projects. The key, in my opinion, is both the composition of members of the team as well as the consistency of the meetings. This set up is integral in forcing the mentee to think creatively and stay on track.”
— Mira Mamtani, MD, ARMED MedEd participant
that endure long after the course is completed.
In summary, the ARMED MedEd program is piloting a family mentorship program that builds upon literature suggesting the benefits of mentoring, community of practice, and networks for professional development, career advancement, research productivity, and increasing diversity and equity in research collaboratives. The family structure maintains the flexibility and benefits of one-on-one mentoring while scaffolding each dyad with a built-in community to promote, collaborate, and enhance accessibility to expertise and resources. This mentorship structure may be applied to other professional development programs, either locally or nationally, and program evaluation will focus on determining the effectiveness of the structure in achieving the ARMED MedEd aims. ABOUT THE AUTHORS
Dr. Coates is a professor of emergency medicine at UCLA Geffen School of Medicine/ Harbor-UCLA Emergency Medicine where she specializes in education research. She currently serves as the secretary-treasurer on the SAEM Board of Directors and is a co-chair of ARMED MedEd. Dr. Yarris is professor of emergency medicine at Oregon Health & Science University and vice chair for faculty development, education section director, and co-director of the education scholarship fellowship. She is deputy editor for the Journal of Graduate Medical Education and co-chair of ARMED MedEd. ARMED MedEd Steering Committee: Drs. Holly Caretta-Weyer, Teresa Chan, Sam Clarke, Wendy Coates, Michael Gottlieb, Jon Ilgen, Jaime Jordan, Anne Messman, Teresa Smith, Stefanie Sebok-Syer, Lainie Yarris. With special thanks to the SAEM task force that created the ARMED MedEd program: Drs. Teresa Chan, Sam Clarke, Wendy Coates, Michael Gottlieb, Jon Ilgen, Jaime Jordan, LuAnn Lawson, Anne Messman, Phillip Moschella, Dan Runde, Sally Santen, Lainie Yarris.
By Helena Halasz, MD and Shuhan He, MD, on behalf of the SAEM Virtual Presence Committee
In the fall of 2020, emergency medicine residency programs were faced with an unprecedented application season, which entailed not only fighting COVID-19 at the frontlines, but also meeting and interviewing applications virtually for the first time. Programs that had previously had minimal online presence scrambled to improve outreach when the Council of Residency Directions of Emergency Medicine (CORD-EM) recommendation was announced, and emergency medicine programs across the country found that they had to rely on their websites and social media pages to connect with applicants.
Now, as our specialty is gearing up for another residency application cycle, the recommendation for interviews will likely remain the same: stay safe, stay virtual. This time around, however, programs have a little more time to prepare and thus a singular chance to improve their digital presence.
For those without a background in computer science, it can be difficult to ascertain what makes a website “good.” A study published in June 2021 in SAEM AEM Education and Training (Website usability analysis of United States emergency medicine residencies) conducted a cross-sectional usability audit of emergency medicine residency program websites and used four quantifiable characteristics to analyze each one. In total, it studied 55 emergency medicine programs and evaluated each based on accessibility, marketing, content quality and technology.
Accessibility analyzed the ability of users with lower levels of computer literacy to successfully navigate a website. It considered the meta description, or “snippet” page summary that appears on search engines, the functionality, the readability, and the overall layout.
Content quality looked at relevance of written text, including content related to application requirements, curriculum details, benefits, etc., as well as grammar and spelling. It also analyzed the generated metadata, which functions as important supporting information (for example, descriptions of photos), and scored multimedia based on quantity and quality (i.e., resolution). Marketing examined the ease of discovery of each website, based on the order in which websites are displayed in search engine searches. This property, known as a search engine results pages (SERPs), determines which website has better discoverability, and is intricately intertwined with search engine optimization (SEO). Technology addressed a website’s technical functionality, looking at the quality of technological design and performance. It examined both front-end design (which is what the user can see when visiting a webpage), and back-end design (which is the code that runs the website). The study determined a general usability score, which used the previous four metrics to assess the overall quality of a website; this was found to be low performing across most EM residency programs. This information can serve as a starting point for EM residencies to begin an audit of their own websites. The study further found that content quality was the highest mean scoring category and that technology was the lowest performing category. It is clear that EM residencies have placed heavy emphasis on providing accurate and relevant information about their programs, which is important, but this usability analysis demonstrates that upon closer inspection, there are many aspects that programs could improve. Using the results of this study, emergency medicine programs have the unique ability to troubleshoot their own websites and make improvements, thus facilitating the spreading of information as more and more applicants browse their websites. ABOUT THE AUTHORS Dr. Halasz is a recent graduate of Semmelweis University (Budapest, Hungary) and an aspiring emergency medicine physician, with a special interest in social EM and bedside ultrasonography Dr. He is an emergency medicine physician and faculty member of Harvard Medical School and in the Lab of Computer Science at Massachusetts General Hospital
Recommendations for improving website usability for EM residency programs:
• perform frequent audits, ensuring information is up to date • assess relevance of information to current applicants • evaluate quality and quantity of multimedia (resolution, layout) • optimize outreach (drive traffic from social media, collaborate with SEO experts) • improve front-end design (make website scalable across devices, enhance navigation)
“You’ve got 1,000 Emails!” The Joys and Pains of Returning to Work
By Al’ai Alvarez, MD; Angela Lumba-Brown, MD; and Stefanie Sebok-Syer, PhD on behalf of the SAEM Wellness Committee
It’s summer, and you recently took two weeks of a much-needed vacation. Pandemic restrictions eased up, and you were able to travel, spend time with family and friends, enjoy new scenes and cuisines, and take lots of photos. It was exactly what you needed to fill your buckets of play, love, and health. The night before your first day back to work, you open your mailbox to find 1,000 emails. *Sigh. Your heart sinks, and the feelings of rest and relaxation are suddenly replaced with anxiety — “How am I going to get through all of these?”
As many of us continue to work from remote office spaces, the translation from previous in-person interactions has led to more emails than pre-pandemic times. In academia, we are constantly challenged to manage our inbox — now more than ever. Endless emails and bottomless inboxes create a wellness tax that is either paid upfront or deferred for our time away from work. It’s no surprise that returning to work from any leave, planned or otherwise, is often met with a stark realization that we’re again already behind. In anticipation of this, most of us do not really go on vacation when we are on vacation. Instead, we continue to sift through messages, responding “only to the really important stuff,” and may even take a meeting or two while “off.” When did the “really important stuff” not include unplugging for well-being? Practicing mindfulness and being present during vacation result in lasting impacts beyond time off. Vacation often spurs creativity, connectivity, and renewed energy and enthusiasm in returning to the workplace — but not for those who take work with them. How, then, do we make the most of our time away without feeling overwhelmed about returning to work? We reached out to several colleagues in academia and social media to better understand ways of easing back to work.
Here are some tips:
1. Begin at the beginning. Schedule dedicated time in the two weeks before taking leave to notify appropriate administrative staff, leadership, and project collaborators. Make a plan of action with these stakeholders to manage urgent issues while you are gone. Dr. Adolfo Barraza Muñoz adds creating a plan of action that includes delegating who will solve contingencies while you are away. Wellness is a team sport. Having someone manage our emails or delegate tasks when we are away allows us to tackle those that immediately require our attention when we return. This supports everyone to take a break and minimizes the guilt of not contributing while away. 2. Set up expectations using an away message. Dr. David Marcus shares setting expectations of when you’ll be
responding to emails and recommends including a request to resend the email again after your return for a faster response. A stronger yet simpler stance would be to state in your away message that emails received during vacation will be deleted. Clare Murphy, an internationally renowned storyteller, shares this away message:
Happy August wherever you are.
Listen, I’ve snuck away for a much needed holiday, a real break. And so to do that effectively I will not be checking my emails. I’m off to the sea and the woods and the wild open spaces.
I’ll get back online Aug 17th, so why not get in touch with me then?
Hope you are well in this paradoxical time.
Holidaying,
Clare 3. Extend the auto-reply away message a few days after your return. This allows senders to know that your inbox will be extra full and that you are working your way to reply to correspondence. 4. Schedule allotted time during your return to tackle your inbox, and stick to it. Often, we’re prone to use the inbox as a to-do list, which adds to our cognitive distractions. Dr. Wendy
Coates shares that “vacations make [us] healthier and better at [our] job.”
She suggests “scheduling a buffer day or two upon return to get reintegrated” and “scheduling time blocks to sort/respond.” She also suggests “sorting inbox by sender” and
“creating rules to filter out junk emails.”
Dr. Teresa Chan outlines these other helpful ways of managing the inbox.
Dr. Adaira Landry and Dr. Resa E.
Lewiss share what a compassionate email culture can look like in this
Harvard Business Review article. 5. Practice self-compassion. Everyone (including YOU, your department leadership, the trainees and administrative staff) deserves time off from work. Leaders may feel particularly guilty taking a break; unfortunately, not taking a vacation may translate to an unrealistic expectation for everyone. We earn our vacation; it is not something to feel bad about. Part of self-care is setting boundaries, recognizing your limits, and doing your best without overdoing your best. 6. Finally, inbox hygiene is not a once-ayear visit — consider scheduling a set time every day to review and respond.
This is best done at an ergonomic workspace that allows for comfortable and efficient reading and typing instead of lying in bed at 2 am, thumbing responses on your smartphone with a blanket pulled over your face to shield your partner from blue light.
As champions in our field, how else can we help each other and our colleagues be more present when they are away from work? In what ways can help to set standards for achieving work-life balance that can shift our current culture? And when will unplugging for personal rest and recovery be considered vital and fully supported in our profession? Join the conversation, but please, don’t send it as an email.
ABOUT THE AUTHORS
Dr. Alvarez is director of wellbeing, Stanford Emergency Medicine, @alvarezzzy
Dr. Lumba-Brown is associate vice chair, Stanford Emergency Medicine
Dr. Sebok-Syer is an instructor, Stanford Emergency Medicine, @stefsebok
