MSHS 503S Midterm (125 points) Part 1. Read the attached paper. The Discussion section has been redacted. The Midterm assignment is to write the Discussion portion of the paper. Your discussion section should include the following points: • Emphasize the major findings of the study. • Explain what the findings mean within the context of the literature at large. (To do this you may wish to review work referenced in the paper – at least the abstract of referenced work.) • Compare and contrast the results with other studies. (To do this you may wish to review work referenced in the paper – at least the abstract of referenced work.) • Explain the importance of the work to the area of simulation. • Discuss limitations of the work including any possible mistakes in methodology, including this you might have done better or differently. • Propose future directions for this type of investigation To this end, you may wish to review the following resources on writing a Discussion section. • http://www.sfedit.net/discussion.pdf • https://nicholas.duke.edu/sites/default/files/effective_discussion.pdf • https://oup.silverchaircdn.com/oup/backfile/Content_public/Journal/jpepsy/34/4/10.1093/jpep sy/jsp014/2/jsp014.pdf?Expires=1487256639&Signature=ECqG6zijkM MAuxt-UcZavcuin-SEhZqt09tAUfZCtt-PsXqpmDBG4DcotwfPEko4- WPFO0HVm7xHvFzRllcrmrzQ3gNYaS0wDlbM6PX1AxCiMMU02DRkCMSsvD8kGxjJiA72g7zlIGaF2pKsj0 N5Id0waUwIAX6aRhWUcJKZQ2MV84gapnLbayTm1IeQZajco5ItBiF3 Q9CVbSGWqUk~hTsf7s14epRGfvUjWLCdCr726fobubtUwg9lNy78y~N50Y7y6RFczLcomeVJnqc0KlGWq90HTL uDLZolIgzAJc3uHKGCMizQ5rCZO1sJibGu0Y5kDsbnejfUuL7JeTpQ__ &Key-Pair-Id=APKAIUCZBIA4LVPAVW3Q Part 1 is worth 100 points and will be graded using the following rubric. • Major Findings (15 points) – major findings must be included. This is not an exhaustive restatement of the results, but a highlight of the post important results followed by possible explanations.• Explanation of Findings (30 points) – this is the most important part of the Discussion. Explain, interpret, give meaning to the results. • Compare and contrast (15 points) – a good Discussion section place the current research in context of past research, where does not fit in reference to all the other work? • Limitations (10 points) – to be complete you must discuss limitations of the work. What could they have done better? Despite limitations, problems can you defend them? Was appropriate methodology used? • Future Directions (10 points) – a section discussing future ideas for research must be included. • Format (5 points) – the format must be consistent with what it found in the literature. No bullet points responding to the results. It should be able to be used in lieu of the current Discussion section. For a guide as to length the original Discussion section was about 1000 words; two pages 12 point Times New Roman font, 1.15 line spacing. While I don't expect this much, I would not think you could do an adequate job writing a Discussion section in less than one page (≈500 words). Lengthier works are accepted. • References (10 points) – any references used should be cited in APA format. • Grammar, punctuation, & spelling (5 points) – the submission is expected to be free from grammatical, punctuation, and spelling errors. Written submissions must be submitted through Blackboard. Oral Presentations should post a copy of the email they send to me on Blackboard as proof of meeting the deadline. (In other words, create your presentation, email it to me as an attachment, and then print the email electronically, and save it as a PDF. Post the PDF of the email on Blackboard. Late submissions will receive zero (0) credit. No exceptions.TOXICOLOGY INVESTIGATION A Comparison of Simulation-Based Education Versus Lecture-Based Instruction for Toxicology Training in Emergency Medicine Residents Joseph K. Maddry & Shawn M. Varney & Daniel Sessions & Kennon Heard & Robert E. Thaxton & Victoria J. Ganem & Lee A. Zarzabal & Vikhyat S. Bebarta Published online: 21 May 2014 # American College of Medical Toxicology (outside the USA) 2014 Abstract Simulation-based teaching (SIM) is a common method for medical education. SIM exposes residents to uncommon scenarios that require critical, timely actions. SIM may be a valuable training method for critically ill poisoned patients whose diagnosis and treatment depend on key clinical findings. Our objective was to compare medical simulation (SIM) to traditional lecture-based instruction (LEC) for training emergency medicine (EM) residents in the acute management of critically ill poisoned patients. EM residents completed two pre-intervention questionnaires: (1) a 24-item multiplechoice test of four toxicological emergencies and (2) a questionnaire using a five-point Likert scale to rate the residents' comfort level in diagnosing and treating patients with specific toxicological emergencies. After completing the preintervention questionnaires, residents were randomized to SIM or LEC instruction. Two toxicologists and three EM physicians presented four toxicology topics to both groups in four 20-min sessions. One group was in the simulation center, and the other in a lecture hall. Each group then repeated the multiple-choice test and questionnaire immediately after instruction and again at 3 months after training. Answers were not discussed. The primary outcome was comparison of immediate mean post-intervention test scores and final scores 3 months later between SIM and LEC groups. Test score outcomes between groups were compared at each time point (pre-test, post-instruction, 3-month follow-up) using Wilcoxon rank sum test. Data were summarized by descriptive statistics. Continuous variables were characterized by means (SD) and tested using t tests or Wilcoxon rank sum. Categorical variables were summarized by frequencies (%) and compared between training groups with chi-square or Fisher's exact test. Thirty-two EM residents completed preand post-intervention tests and comfort questionnaires on the study day. Both groups had higher post-intervention mean test scores (p<0.001), but the LEC group showed a greater improvement compared to the SIM group (5.6 [2.3] points vs. 3.6 [2.4], p=0.02). At the 3-month follow-up, 24 (75 %) tests and questionnaires were completed. There was no improvement in 3-month mean test scores in either group compared to immediate post-test scores. The SIM group had higher final mean test scores than the LEC group (16.6 [3.1] vs. 13.3 [2.2], p=0.009). SIM and LEC groups reported similar diagnosis and treatment comfort level scores at baseline and improved equally after instruction. At 3 months, there was no difference between groups in comfort level scores for diagnosis or treatment. Lecture-based teaching was more effective than simulation-based instruction immediately after intervention. At 3 months, the SIM group showed greater retention than the LEC group. Resident comfort levels for diagnosis and treatment were similar regardless of the type of education. Keywords Toxicology . Simulation . Education . Training . Residency Introduction Poisoned, critically ill patients often require specific, urgent interventions that must be initiated after a diagnosis based on limited history and physical examination findings. Rapid Electronic supplementary material The online version of this article (doi:10.1007/s13181-014-0401-8) contains supplementary material, which is available to authorized users. J. K. Maddry (*): S. M. Varney: D. Sessions: R. E. Thaxton: V. J. Ganem: L. A. Zarzabal: V. S. Bebarta San Antonio Military Medical Center, Ft Sam Houston, TX, USA e-mail: [email protected] K. Heard Rocky Mountain Poison and Drug Center, Denver, CO, USA J. Med. Toxicol. (2014) 10:364–368 DOI 10.1007/s13181-014-0401-8identification and appropriate treatment of a poisoned patient can have significant clinical impact as evidenced by poisoned patients with life-threatening dysrhythmias having survival rates as high as 50 % with appropriate management [1, 2]. The benefit of identification and treatment of the critically ill poisoned patient highlights the importance of appropriate emergency medicine resident education. The rarity of life-threatening poisonings leaves emergency physicians in training with little and random clinical experience. Examples of such poisonings include serotonin syndrome, severe salicylism, tricyclic antidepressant-induced ventricular tachycardia, or organophosphorous compound poisoning. Alternative and engaging education approaches have been used for trauma resuscitation, advanced cardiac life support, military combat casualty care, and pilot training [3]. The airline industry has used simulation for decades to train pilots to handle unexpected disaster or events [3, 4]. Simulation training may be an appropriate modality to teach the identification and management of toxicologic emergencies to emergency medicine residents. The benefits of medical simulation include the ability to allow the learner to manage a medical challenge and learn from mistakes without placing an actual patient at risk [5–7]. Despite the growth of medical simulation used in medical education, research into the appropriate application and its benefits is limited. Most simulation-based medical education (SBME) studies are observational evaluations of the learners' self-reported satisfaction with the simulation experience with no objective findings [8, 9]. The few randomized controlled studies reported improved performance in the SBME groups compared to the control groups (lecture-based education); however, in most of these studies, a significantly greater amount of time was spent training the subjects in the SBME arm than in the control arm. Thus, it was unclear if the subjects in the simulation arms performed better because simulation was superior to lecture or if because more time was spent training them [8, 10]. One published study evaluated the use of simulation in toxicology education, but this study included exclusively second year medical students [11]. We hypothesized that training emergency medicine residents with SBME would improve their medical knowledge and confidence compared to traditional lecture-based education at 3 months after training. Methods Study Design We conducted a prospective randomized controlled trial of mannequin simulation versus lecture. The San Antonio Military Medical Center Institutional Review Board approved the study. Study Setting and Population Residents at a single 3-year emergency medicine residency were the subjects of the study. Simulation training was conducted by the hospital's graduate medical education simulation center using Laerdal SimMan® 3G patient simulators (product number 212-00050; Wappingers Falls, NY). Study Protocol Residents were assigned to either a simulation arm or control arm using block randomization based upon the residents' current level of training (e.g. first-year, second-year, or third-year resident). Sixteen residents were assigned to the simulation arm, and 17 were assigned to the lecture arm. The simulation arm was then further randomly divided into four near-equal teams (three teams of four subjects and one team of five subjects) with at least one first-, second-, and thirdyear emergency medicine resident on each team. Subjects on the four simulation teams were presented in series with each of four high-fidelity mannequinbased medical simulation cases (beta-blocker and calcium channel antagonist toxicity, organophosphorous compound poisoning, salicylate toxicity, and tricyclic antidepressant poisoning). Following the completion of the case, the instructor used the remainder of the 20 min available to review the case and provide additional teaching. The groups then rotated to the next station. Each of the four instructors was assigned to present the same case to each of the four teams assigned to the simulation arm. The instructors were also cautioned to ensure the simulation session progressed rapidly enough to allow sufficient time for debriefing at the end. All four instructors were boardcertified emergency physicians, and one was also board certified in medical toxicology. Each instructor was provided a simulation case and trained in a standard format by the research team on how to conduct the simulation training (instructor training documents available for review online). The 16 subjects assigned to the control arm were given a 20-min lecture on each of the four aforementioned topics (beta-blocker and calcium channel antagonist toxicity, organophosphorous compound poisoning, salicylate toxicity, and tricyclic antidepressant poisoning) with a break for questions between each lecture. A boardcertified emergency physician in the second year of medical toxicology fellowship training provided the four lectures. The lecturer was also directed to ensure all pertinent information was covered but to refrain from directing his teaching specifically towards the test questions. J. Med. Toxicol. (2014) 10:364–368 365Measurements The subjects were given an identical pre-intervention and post-intervention questionnaire and test immediately before and immediately after the educational intervention (simulation or lecture). The questionnaire and test were also administered again 3 months following the intervention to assess for knowledge retention. The questionnaire assessed the subject's comfort level in diagnosing and managing each of the four different toxicities as well as their overall comfort level using a sixpoint Likert scale. The test consisted of 24 vignette-based questions (6 questions for each of the four topics). The test questions and the simulation instructor teaching documents were developed by the investigators utilizing the American Board of Emergency Medicine (ABEM) core competencies and are available to view. The primary outcome was comparison between the simulation (SIM) and lecture (LEC) groups' mean test scores at 3 months post-intervention. Data Analysis Test score outcomes between groups were compared at each time point (pre-test, post-instruction, 3-month follow-up) using Wilcoxon rank sum test. Data were summarized by descriptive statistics. Continuous variables were characterized by means (SD), and the means were tested using t tests or Wilcoxon rank sum. Categorical variables were summarized by frequencies (%) and compared between training groups with chi-square or Fisher's exact test. Mean test scores were compared using a two-sample t test. Results Thirty-three EM residents completed pre- and post-intervention tests and comfort questionnaires on the study day (Table 1). SIM and LEC groups had similar mean pre-intervention baseline test scores. Both groups had higher post-intervention mean test scores (p<0.001), and the LEC group showed a greater improvement compared to the SIM group (5.6 [2.3] point increase vs. 3.6 [2.4] point increase, p=0.02). At the 3-month follow-up, 24 (75 %) tests and questionnaires were completed (11 in the simulation group and 13 in the lecture arm). The SIM group had higher final mean test scores than the LEC group (16.6 [3.1] vs. 13.3 [2.2], p=0.009, Fig. 1). When comparing the immediate post-intervention test scores of those who did and did not complete the 3-month post-intervention test, there was no significant difference between the simulation (17 [1.9] vs. 18.4[2.1], p=0.18) and lecture (18.1[2.7] vs. 18.2[1.7], p=0.95) arms. SIM and LEC groups reported similar diagnosis and treatment comfort level scores at baseline and improved equally after instruction (Table 2). At 3 months, there was no difference between groups in comfort level scores for diagnosis or treatment. Table 1 A list of demographic characteristics for the subjects enrolled in each arm of the study Training groups Simulation Lecture Total Subjects, n (%) 16 (100) 17 (100) 33 (100) Age (years), n (%) 25 to 30 11 (68.75) 12 (70.59) 23 (69.7) 31 to 35 5 (31.25) 4 (23.53) 9 (27.27) 36 to 40 0 (0) 1 (5.88) 1 (3.03) Gender, n (%) Female 2 (12.5) 4 (23.53) 6 (18.18) Male 14 (87.5) 13 (76.47) 27 (81.82) Current year of EM residency, n (%) 1st 6 (37.5) 7 (41.18) 13 (39.39) 2nd 6 (37.5) 6 (35.29) 12 (36.36) 3rd 4 (25) 4 (23.53) 8 (24.24) Years of clinical experience, n (%) n/a 11 (68.75) 12 (70.59) 23 (69.7) 1 4 (25) 3 (17.65) 7 (21.21) 3 0 (0) 1 (5.88) 1 (3.03) ≥4 1 (6.25) 1 (5.88) 2 (6.06) Completed tox rotation, n (%) Yes 2 (12.5) 2 (11.76) 4 (12.12) No 14 (87.5) 15 (88.24) 29 (87.88) EM emergency medicine Fig. 1 Composite test scores The test scores for each training class (Sim vs Lect) at each testing period (Pre, Post, 3Mo Post) are represented by box-andwhisker plots. For each box-and-whisker plot, the solid dark line represents the median Test score. The bottom and top of the box represent the interquartile range (1st and 3rd quartiles). The whiskers represent the minimum and maximum scores excluding outliers. The circles represent outlier values 366 J. Med. Toxicol. (2014) 10:364–368Table 2 Comfort composite scores by training group Training Groups Simulation Lecture Composite comfort scorea Pre (n=16) Post (n=16) 3 months (n=11) Pre (n=17) Post (n=17) 3 months (n=13) Diagnosingb 12.75 (3.94) 10.13 (3.12) 10.91 (3.05) 12.88 (4.73) 11.53 (4.52) 13 (4.71) Treatingc 13.31 (4.61) 10.63 (3.54) 10.91 (3.56) 13.12 (4.54) 11.24 (4.63) 12.85 (4.67) Overall comfortd 26.06 (8.45) 20.75 (6.48) 21.82 (6.49) 26 (9.16) 22.76 (9.07) 25.85 (9.2) Questionnaires are available online. A lower numerical value indicates a higher level of comfort a Composite scores are represented by means (standard deviation) by training group for each testing follow-up period b Composite score for diagnosing comfort (questions 8,9,11,13,15) c Composite score for treating comfort (questions 7,10,12,14,16) d Composite score for overall (questions 7 through 16) J. Med. Toxicol. (2014) 10:364–368 367References 1. Dasgupta A, Emerson L (1998) Neutralization of cardiac toxins oleandrin, oleandrigenin, bufalin, and cinobufotalin by Digibind: monitoring the effect by measuring free digitoxin concentrations. Life Sci 63:781 2. Lapostolle F, Borron SW, Verdier C et al (2008) Digoxin-specific Fab fragments as single first-line therapy in digitalis poisoning. Crit Care Med 36:3014 3. Bond WF, Lammers RL, Spillane LL, Smith-Coggins R, Fernandez R, Reznek MA, Vozenilek JA et al (2007) The use of simulation in emergency medicine: a research agenda. Acad Emerg Med 14(4): 353–363 4. Issenberg SB, Scalese RJ (2008) Simulation in health care education. Perspect Biol Med 51(1):31–46 5. Rosen KR, McBride JM, Drake RL (2009) The use of simulation in medical education to enhance students' understanding of basic sciences. Med Teach 31(9):842–846 6. Holmstrom SW, Downes K, Mayer JC, Learman LA (2011) Simulation training in an obstetric clerkship: a randomized controlled trial. Obstet Gynecol 118(3):649–654 7. Ziv A, Ben-David S, Ziv M (2005) Simulation based medical education: an opportunity to learn from errors. Med Teach 27(3):193–199 8. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ et al (2011) Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA 306(9):978–988 9. McFetrich J (2006) A structured literature review on the use of high fidelity patient simulators for teaching in emergency medicine. Emerg Med J 23(7):509–511 10. Lam G, Ayas NT, Griesdale DE, Peets AD (2010) Medical simulation in respiratory and critical care medicine. Lung 188(6):445–457 11. Halm BM, Lee MT, Franke AA (2010) Improving medical student toxicology knowledge and self-confidence using mannequin simulation. Hawaii Med J 69(1):4–7 12. Zigmont JJ, Kappus LJ, Sudikoff SN (2011) Theoretical foundations of learning through simulation. Semin Perinatol 35(2):47–51 13. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ (2005) Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 27(1):10–28 14. Yarris LM, Deiorio NM (2011) Education research: a primer for educators in emergency medicine. Acad Emerg Med 18(Suppl 2): S27–S35 368 J. Med. Toxicol. (2014) 10:364–368Part 2. Given the following scenario do you have reason to suspect salami slicing? A prospective study comprised of certification scores of bag valve mask (BVM), advanced cardiac life support skills (ACLS), and moderate sedation (MS) in emergency medicine residents. There were two groups, residents using a purely didactic curriculum and residents using a deliberate-practice mastery learning curriculum. Within a short period of time, two articles with similar titles were published with no cross reference to each other. One article presented compared the use of deliberate-practice mastery learning and didactic curriculum for passage or failure of all three skills. The other article assessed the long-term effects of a deliberate-practice mastery learning on knowledge retention versus that of knowledge retention of those skills in residents taught using a didactic curriculum. Part 2 is worth 12.5 points and will be graded according to the following rubric. • Judgement (5 points) – make a determination as to whether the proposed hypothetical article is salami slicing. • Defense of position (5 points) – based on your determination, justify your answer. Defend your position, argue your point. A justifiable defense of the wrong answer will receive full credit. The exercise is about your reasoning and critical thinking skills. • Grammar, punctuation, spelling, references (2.5 points) – the submission is expected to be free from grammatical, punctuation, and spelling errors. References must be in APA format. • Late submissions will receive zero (0) credit. No exceptions. Part 3. Given the following paper, what is your opinion as to the methodology used? Part 3 is worth 12.5 points and will be graded according to the following rubric. • Judgement as to methodology used (5 points) – make a determination as to whether appropriate methodology was used in this investigation. • Defense of position (5 points) – based on your determination, justify your answer. Defend your position, argue your point. What are the implications of the methodology. The exercise is about your reasoning and critical thinking skills. • Grammar, punctuation, spelling, references (2.5 points) – the submission is expected to be free from grammatical, punctuation, and spelling errors. References must be in APA format. • Late submissions will receive zero (0) credit. No exceptions.Western Journal of Emergency Medicine 146 Volume XVIII, no. 1: January 2017 Original research Characteristics of Real-Time, Non-Critical Incident Debriefng Practices in the Emergency Department Nur-Ain Nadir, MD, MEHP(c)*¶ Suzanne Bentley, MD, MPH† Dimitrios Papanagnou, MD MPH‡ Komal Bajaj, MD§ Stephan Rinnert, MD¶ Richard Sinert, DO¶ Section Editor: David A. Wald, DO Submission history: Submitted July 8, 2016; Revision received October 3, 2016; Accepted October 27, 2016 Electronically published December 5, 2016 Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.2016.10.31467 OSF St. Francis Medical Center, University of Illinois College of Medicine at Peoria, Department of Emergency Medicine, Peoria, Illinois Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine and Department of Medical Education, Elmhurst, New York Thomas Jefferson University Hospital, Department of Emergency Medicine, Philadelphia, Pennsylvania Jacobi Medical Center, Department of Obstetrics and Gynecology, New York, New York Kings County Hospital and SUNY Downstate Medical Center, Department of Emergency Medicine, New York, New York * † ‡ § ¶ Introduction: Benefts of post-simulation debriefngs as an educational and feedback tool have been widely accepted for nearly a decade. Real-time, non-critical incident debriefng is similar to post-simulation debriefng; however, data on its practice in academic emergency departments (ED), is limited. Although tools such as TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety) suggest debriefng after complicated medical situations, they do not teach debriefng skills suited to this purpose. Anecdotal evidence suggests that real-time debriefngs (or non-critical incident debriefngs) do in fact occur in academic EDs;, however, limited research has been performed on this subject. The objective of this study was to characterize real-time, non-critical incident debriefng practices in emergency medicine (EM). Methods: We conducted this multicenter cross-sectional study of EM attendings and residents at four large, high-volume, academic EM residency programs in New York City. Questionnaire design was based on a Delphi panel and pilot testing with expert panel. We sought a convenience sample from a potential pool of approximately 300 physicians across the four sites with the goal of obtaining >100 responses. The survey was sent electronically to the four residency list-serves with a total of six monthly completion reminder emails. We collected all data electronically and anonymously using SurveyMonkey.com; the data were then entered into and analyzed with Microsoft Excel. Results: The data elucidate various characteristics of current real-time debriefng trends in EM, including its defnition, perceived benefts and barriers, as well as the variety of formats of debriefngs currently being conducted. Conclusion: This survey regarding the practice of real-time, non-critical incident debriefngs in four major academic EM programs within New York City sheds light on three major, pertinent points: 1) real-time, non-critical incident debriefng defnitely occurs in academic emergency practice; 2) in general, realtime debriefng is perceived to be of some value with respect to education, systems and performance improvement; 3) although it is practiced by clinicians, most report no formal training in actual debriefng techniques. Further study is needed to clarify actual benefts of real-time/non-critical incident debriefng as well as details on potential pitfalls of this practice and recommendations for best practices for use. [West J Emerg Med. 2017;18(1)146-151.]Volume XVIII, no. 1: January 2017 147 Western Journal of Emergency Medicine Nadir et al. Real-Time, Non-Critical Incident Debriefng Practices in the ED INTRODUCTION The emergency department (ED) is a complicated teaching environment. Prolonged patient waiting times, frequent interruptions, a diverse set of learners and a variety of emergent, often unpredictable clinical cases compounded with XnderstaIfng and limited resoXrces reSresent the maMor barriers to effective bedside teaching and provision of feedback to trainees. This challenging learning environment maNes a strong argXment Ior ED-sSecifc teaching and learning strategies.1-3 Anecdotal reports suggest that one teaching tool and feedback strategy being employed by emergency medicine (EM) faculty is real-time, non-critical incident debriefng Real-time feedback during a clinical shift in the ED is an important component of a resident physician's medical education and can have a profound impact on clinical practice.2-5 Despite this, many residents feel they do not get adequate or useful feedback during their clinical shifts. 6Secifc, tailored, learner-centered IeedbacN is crXcial bXt rarely performed.2-5 Debriefng is an edXcational tool based on the SrinciSles of adult learning theory that uses a simulated (or real) medical event to generate a discussion of the teachable moments within that event.6 Debriefngs are critical to healthcare education because that is usually where the critical process of IeedbacN occXrs and Zhere learning is oIten clarifed and translated into "take-home points" and guidelines for future practice.7,8 An example of such an event would be a resident physician encountering a challenging, agitated patient. The teachable oSSortXnit\ ZoXld inclXde a debriefng oI the diIfcXlties encoXntered b\ the resident and Zhat Zent smoothly versus what could have been performed differently. Debriefng can be YieZed as a conYersation aboXt a medical event, where any observed clinical performance gaps are addressed.9 Learners are asked open-ended questions in order to clarify their individual thought processes and are also asked to self-critique their performance.11,13,14 By promoting constructive self-critique and self-evaluation, medical debriefng instills Sractices oI liIe-long learning, considered to be important elements of "practice-based learning," one of the six core medical education competencies required by the Accreditation Council of Graduate Medical Education..15 Research has clearly established the importance of IeedbacN Debriefng bXilds on man\ tenets oI IeedbacN including recommendations that it should be timely, sSecifc, tailored, and learner centered.11,13-14 Most of this research, however, has been conducted in simulated environments. With the advent of communication tools such as TeamSTEPPS16 (Team Strategies and Tools to Enhance Performance and Patient 6aIet\, debriefng is Sromoted as a means oI selI-reÀection in order to lead to systems and process improvement. METHODS We recruited four EM residency programs for the purposes of this study. These four programs were chosen because they are large, high-volume, academic teaching hospitals within the city of New York. We contacted residency leadership from each hospital and obtained permission to distribute a questionnaire to EM staff. Questionnaire design commenced with a PubMed literature search using the terms ³medical debriefng,´ ³simXlation debriefng,´ ³non-critical incident debriefng´ and ³real-time debriefng´ :e then identifed maMor landmarN articles on medical edXcational debriefng Sractices, techniTXes, and sNills ³Critical incident debriefng´ and similar Ss\chological debriefng articles Zere excluded. Based on the literature search, we drafted a TXestionnaire e[amining basic characteristics oI debriefng :e identifed E0 edXcators and simXlation debriefng experts based on their respective research publications and/or inYolYement in the felds oI E0 and healthcare simXlation and invited them to participate in a Delphi panel for further refnement oI the TXestionnaire )eedbacN Irom the DelShi panel of six experts was incorporated into a second version of the questionnaire that was reviewed by the Delphi panel experts. It was then pilot-tested with a group of 10 emergency Sh\sicians )eedbacN regarding Shraseolog\ and TXestion order Zas incorSorated into the fnal sXrYe\ see $SSendi[ We sought a cross-sectional, convenience sample from a potential pool of approximately 300 physicians across the four sites with the goal of obtaining >100 responses. A sample size goal oI  Zas institXted Ior this Sreliminar\ sXrYe\ SroMect convenience sample in order to include approximately 10 sXbMects Ser eYer\ one sXrYe\ item The sXrYe\ Zas sent electronically to the four residency listserves from December 2012 to June 2013, with a total of six monthly completion reminder emails. We collected results electronically and anonymously using SurveyMonkey.com. All data were analyzed using Microsoft Excel. This study was deemed exempt by the local institutional review board. RESULTS We collected 157 responses, representing a response rate between 45% and 52%. Of the respondents, 52% were resident physicians and 47% were attending physicians. No other demograShic data Zere collected )iIt\-nine Sercent oI our respondents reported participating in non-critical incident debriefng in clinical and simXlated settings, Zhereas   reSorted debriefng onl\ dXring clinical Sractice )igXre a * "Critical incident debriefng" or "critical incident stress debriefng" are well established terms in psychological literature, that refer to a deliberate counseling method designed to mitigate the stress response generated from emotionally traumatic cases or "critical incidents" such as pediatric deaths or mass casualty events.17 As "critical incident debriefng" focuses on stress mitigation and not education, process or systems improvement, it was excluded from the literature search.Western Journal of Emergency Medicine 148 Volume XVIII, no. 1: January 2017 Real-Time, Non-Critical Incident Debriefng Practices in the ED Nadir et al. :hen asNed Zhat debriefng meant to Sh\sicians,   reported that it was a discussion based on real or simulated cases Zhere SarticiSants selI-reÀect and selI-anal\]e their actions and emotions to improve or sustain performance in the future. Other responses are depicted in Table 1a. With respect to whether respondents had been formally trained in an\ debriefng techniTXe, onl\  reSorted aIfrmatiYel\ )igXre c 6eYeral comments in this section sSecifed that resSondents had learned debriefng sNills b\ watching colleagues or had learned it during simulation debriefng coXrses There Zas signifcant interest in Iormal debriefng training in the groXS sXrYe\ed )igXre b Thirt\ Sercent oI oXr resSondents reSorted debriefng on clinical shifts between 1-3 times monthly. Three percent reSorted debriefng betZeen - times monthl\ The maMorit\ oI resSondents ansZered less than one debriefng a month )igXre d PerceiYed benefts oI real-time debriefngs are deSicted in Table e The maMorit\ oI resSondents indicated that the\ SerceiYe debriefngs to be benefcial Ior clearing the air aIter an event (47%), providing feedback to learners and colleagues (66%), identifying knowledge and process gaps (55%), identifying systems errors (55%), promoting of team unity and cohesiveness (37%) and identifying medico-legal ramifcations  :ith resSect to the Iormats oI real-time debriefngs condXcted, )igXre b  oI resSondents reSorted that debriefngs Zere SerIormed as a groXS, Zhile  reSorted that debriefngs inclXded other SroIessions sXch as nXrsing and ancillary staff; 22.9% reported performing individualized debriefngs Ior each learner 2nl\  reSorted inclXsion oI other specialties, and in the "comments" section several resSondent noted that interdisciSlinar\ debriefngs Zere oIten met with resistance from the other specialties. Table d reÀects the diIIerent Ninds oI sitXations that emergenc\ Sh\sicians are most liNel\ to debrieI The maMorit\ oI resSondents reSorted debriefng aboXt adYerse eYents, near-adverse events, if a colleague was visibly emotionally XSset, diIfcXlties dXring clinical SrocedXres, and miscommunication or poor teamwork; 24.8% reported debriefng aIter eYer\ cardiac code and   aIter eYer\ traXma code 2ne resSondent commented that each debriefng Figure (1a-1d). Practice of real-time debriefng a) Percentage participation in simulated and/or real-time non-critical incident debriefngs b) Percentage with formal training in debriefng skills c) Percentage expressing interest in formal debriefng training d) Reported percentages of debriefngs occurring per month.Volume XVIII, no. 1: January 2017 149 Western Journal of Emergency Medicine Nadir et al. Real-Time, Non-Critical Incident Debriefng Practices in the ED was followed up with a personal email to learners to reinforce clinical Soints learned dXring debriefngs 6eYeral barriers to real-time medical debriefng Zere reported by respondents as illustrated in Table 1c; 85.4% reSorted lacN oI time dXring a bXs\ clinical shiIt as a maMor deterrent. Other barriers included lack of appropriate training (48.4%), lack of space (35.7%), disinterested colleagues (34.4%) and work environment considerations such as confrontational or defensive co-workers (29.9%). Under "comments" for this question, it was noted by a IeZ resSondents that debriefng Zas not stressed enoXgh in curricula and therefore was often not on the academic physicians' radar. DISCUSSION Real-time feedback, such as that accomplished through Characteristics of Real-Time Debriefng Practices Percentage responses (n) 1a. Emergency physicians' understanding of "debriefng" i) A discussion based on a real or simulated case scenario about its management. ii) A post-medical error discussion at an administrative level such as Root Cause Analysis/ or morbidity and mortality Conference iii) A discussion, based on real or simulated cases, aimed at identifying knowledge or performance gaps iv) A discussion, based on real or simulated cases, where participants self-refect and analyze their actions and emotions, to improve or sustain performance in the future 45.9 (72) 12.7 (20) 51.6 (81) 87.9 (138) 1b. Formats of real-time debriefngs being performed i) Separately for each individual learner ii) Group of learners (residents or medical students) iii) Inter-professional (with nursing and/or ancillary support staff) iv) Interdisciplinary v) Initially as a group followed by individually for learners 22.9 (36) 84.1 (132) 37.6 (59) 15.3 (24) 13.4 (21) 1c. Perceived barriers to real-time debriefng i) A lack of training in debriefng skills ii) Time constraints iii) Disinterested colleagues iv) Lack of appropriate space v) Work environment considerations (emotional/ defensive/confrontational co-workers) 48.4 (76) 85.4 (134) 34.4 (56) 35.7 (54) 29.9 (47) 1d. Situations most likely to be debriefed i) Emotionally upset colleagues ii) Adverse event iii) Near-adverse event iv) Diffculties in clinical procedure performance v) Miscommunications and poor teamwork vi) Emotionally charged resuscitations vii) All cardiac codes viii) All trauma codes ix) All of the above 66.2 (104) 68.8 (108) 59.2 (93) 59.2 (93) 65.6 (103) 58.0 (91) 24.8 (39) 25.5 (40) 24.8 (39) 1e. Perceived benefts of real-time debriefngs i) Clears the air ii) Provides a venue for learner and colleague feedback. iii) Provides a venue for addressing learner and colleague knowledge and/or performance gaps iv) Promotes team cohesiveness and unity with respect to patient care v) Provides opportunity for discussion of the medico-legal ramifcations of adverse or near-adverse events vi) Identifes systems errors leading to systems-process improvements vii) All of the above 42.0 (66) 65.6 (103) 54.8 (86) 55.4 (87) 15.9 (25) 59.8 (94) 36.9 (58) Table. Characteristics of real-time debriefng as perceived and understood by emergency physicians. real-time debriefng dXring a clinical shiIt in the ED is an important component of a resident physician's medical education and can have a profound impact on clinical practice.2-5 Debriefngs are signifcant becaXse the\ SroYide a YenXe Ior the crXcial Srocesses oI IeedbacN, reÀection and experiential learning that lead to clinical practice pearls for each learner.7,8 The resXlts Irom this stXd\ confrm that real-time debriefngs occXr IreTXentl\ in EDs desSite onl\  oI resSondents reSorting Iormal training in debriefng techniTXes The maMorit\ oI resSondents ZoXld liNe Iormal training, reÀecting groZing aZareness oI the Sotential benefts oI real-time debriefng $lthoXgh there aSSears to be a SerceiYed YalXe oI the IeedbacN Irom debriefng, Zhether there is a SroYen beneft to Satient care, morbidit\, mortalit\ and learner edXcation is diIfcXlt to SinSoint and remains to be inYestigatedWestern Journal of Emergency Medicine 150 Volume XVIII, no. 1: January 2017 Real-Time, Non-Critical Incident Debriefng Practices in the ED Nadir et al. $n\ Sotential SitIalls oI real-time debriefng, sXch as medicolegal ramifcations or Xnstable ZorN enYironment as a conseTXence oI debriefng, also remain to be elXcidated It ZoXld also be interesting and liNel\ benefcial to stXd\ the eIIects oI institXting a deSartment-Zide debriefng Srotocol on learner education, staff interaction and systems/process imSroYement The eIIect oI non-critical incident debriefng on Satient saIet\ is another Sotential area oI research )inall\, as there is little clarit\ on the Iormat oI debriefng techniTXes being used it would be enlightening to investigate which kind oI debriefng occXrs in the ED enYironment 6imXlation debriefng is based on .olb¶s SrinciSles oI experiential learning.15 .olb¶s c\cle oI e[Seriential learning is based on learners¶ e[Seriencing a SarticXlar eYent, reÀecting on that event, conceptualizing it abstractly and actively experimenting with their newly conceptualized knowledge. Experiential learning occurs in clinical practice during medical student clerkships, residency and beyond. Learners experience a SarticXlar clinical case and the\ reÀect on the management of the case. Learners then conceptualize the knowledge and use it when seeing a similar case in the future.15 The assumption in this picture is that learners perform this learning cycle independently. While it may be true for some learners, a Iacilitated aSSroach to reÀection and conceStXali]ation ma\ aide in the learning Srocess Non-critical incident debriefng can be viewed as the facilitation of experiential learning in real time. It can be tailored to complex clinical cases or events. It can be applied to a diverse set of learners, focusing on learner-sSecifc NnoZledge, Srocess or SrocedXral gaSs When involving other disciplines and professions it can also pave the way for effective teamwork. In these ways, real-time, non-critical incident debriefng has the Sotential to address some of the barriers to effective bedside teaching in the academic and non-academic ED mentioned before.1 LIMITATIONS This study is limited by the nature of any survey-based SroMect and the Sotential biases introdXced b\ selI-reSorting )Xrther, it is limited b\ the limited resSonse rate In addition, the survey data provide only a brief glimpse into the practice Satterns and trends relating to debriefngs in academic EDs in one metropolitan city, which may lead to regional bias and may not allow for generalization to national characteristics of this phenomenon. CONCLUSION This survey regarding the practice of real-time, noncritical incident debriefngs in IoXr maMor academic emergenc\ Srograms Zithin NeZ