title: Impact of a physician-in-triage process on resident education.
abstract: BACKGROUND
  Emergency department (ED) crowding negatively impacts patient care quality and efficiency. To reduce crowding many EDs use a physician-in-triage (PIT) process. However, few studies have evaluated the effect of a PIT processes on resident education. Our objective was to determine the impact of a PIT process implementation on resident education within the ED of an academic medical center.
  
  
  METHODS
  We performed a prospective cross-sectional study for a 10-week period from March to June 2011, during operationally historic trended peak patient volume and arrival periods. Emergency medicine residents (three-year program) and faculty, blinded to the research objectives, were asked to evaluate the educational quality of each shift using a 5-point Likert scale. Residents and faculty also completed a questionnaire at the end of the study period assessing the perceived impact of the PIT process on resident education, patient care, satisfaction, and throughput. We compared resident and attending data using Mann-Whitney U tests.
  
  
  RESULTS
  During the study period, 54 residents and attendings worked clinically during the PIT process with 78% completing questionnaires related to the study. Attendings and residents indicated "no impact" of the PIT process on resident education [median Likert score of 3.0, inter-quartile range (IQR): 2-4]. There was no difference in attending and resident perceptions (p-value =0.18). Both groups perceived patient satisfaction to be "positively impacted" [4.0, IQR:2-4 for attendings vs 4.0, IQR:1-5 for residents, p-value =0.75]. Residents perceived more improvement in patient throughput to than attendings [3.5, IQR:3-4 for attendings vs 4.0, IQR:3-5 for residents, p-value =0.006]. Perceived impact on differential diagnosis generation was negative in both groups [2.0, IQR:1-3 vs 2.5, IQR:1-5, p-value = 0.42]. The impact of PIT on selection of diagnostic studies and medical decision making was negative for attendings and neutral for residents: [(2.0, IQR:1-3 vs 3.0, IQR:1-4, p-value =0.10) and (2.0, IQR:1-4 vs 3.0, IQR:1-5, p-value =0.14 respectively].
  
  
  CONCLUSIONS
  Implementation of a PIT process at an academic medical center was not associated with a negative (or positive) perceived impact on resident education. However, attendings and residents felt that differential diagnosis development was negatively impacted. Attendings also felt diagnostic test selection and medical decision-making learning were negatively impacted by the PIT process.
authors.affiliation: Wake Forest University Health Sciences, Department of Emergency Medicine, Winston-Salem, North Carolina.
authors.forename: Bret A
authors.initials: BA
authors.lastname: Nicks
authors.affiliation: Wake Forest University Health Sciences, Department of Emergency Medicine, Winston-Salem, North Carolina.
authors.forename: Simon
authors.initials: S
authors.lastname: Mahler
authors.affiliation: Wake Forest University Health Sciences, Department of Emergency Medicine, Winston-Salem, North Carolina.
authors.forename: David
authors.initials: D
authors.lastname: Manthey
mesh_terms: D000046:Academic Medical Centers; D001291:Attitude of Health Personnel; D003430:Cross-Sectional Studies; D003441:Crowding; D004635:Emergency Medicine / Q000193:education*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D007396:Internship and Residency; D009657:North Carolina; D017060:Patient Satisfaction; D011446:Prospective Studies; D011787:Quality of Health Care; D011795:Surveys and Questionnaires; D014218:Triage / Q000379:methods* / Q000458:organization & administration