CDEM Voice – Topic 360


The Burning Question

A snapshot from the Emergency Medicine Physicians Wellness and Resilience Summit

What is it that separates Emergency Physicians with 30-year-long careers from those who burn out after less than a decade? Why is the rate of burnout higher in our field than in any other medical specialty? What can we do to help stem the epidemic of burnout amongst Emergency Medicine physicians, residents, and students? These questions and many others were tackled at the Emergency Medicine Physicians Wellness and Resilience Summit, held in Dallas in February.


Shanafelt’s eye-opening study in 2015 demonstrated a steadily-rising rate of burnout amongst physicians. This study showed that, between 2011 and 2015, the rate of physicians endorsing at least one symptom of burnout increased from 45% to 54%. The same study revealed that, though Emergency Physicians (EPs) report a higher level of satisfaction with their work-life balance than most specialties, the rate of burnout amongst EPs is the highest of any specialty (Shanafelt 2015). This high level of burnout amongst EPs has been echoed in subsequent studies. The Medscape Lifestyle Study in 2017 re-demonstrated the steadily-increasing rates of burnout amongst all physicians and showed that nearly 60% of Emergency Physicians experience symptoms of burnout, the highest of any specialty.


Even medical students have demonstrated higher levels of burnout than their peers. Brazeau et al demonstrated that matriculating medical students have a lower rate of burnout and depressive symptoms than their age-similar college-graduate peers, but somewhere in medical school that relationship flips, and medical students develop higher levels of burnout and depression than their peers (Brazeau 2014).


There are many reasons why the stressors of medicine, and Emergency Medicine in particular, can cause high rates of burnout and stress. These stressors can vary in importance throughout one’s career. Medical students may find the lack of control and lack of autonomy most frustrating while seasoned providers may be most challenged by the demands of electronic documentation, irregular hours, and lack of administrative support.


The Wellness and Resilience Summit brought together representatives from all of the major Emergency Medicine Groups, including ACEP, AAEM, AACEM, CORD, SAEM, EMRA, RSA, ACGME, and CDEM, to discuss potential solutions to the burnout epidemic. Many ideas were considered as potential areas for intervention or further investigation. All of the findings are currently being written up and will be published to help open a dialogue in our field.


The discussion that focused on our medical students touched on potential initiatives to help teach resilience. More resilient individuals are less susceptible to the stressors of our job and experience less burnout. Emergency Medicine is a stressful field, and we want to give our students and residents the tools they need to have long, rewarding careers. The next step for CDEM is to start investigating the role we can play in mitigating burnout. Through the cooperation of multiple professional organizations, we can help reverse the tide of ever-increasing burnout in our field.


Emily Fisher MD

on behalf of the Emergency Medicine Physicians Wellness and Resilience Summit


Brazeau C, Shanafelt T, Durning S, Massie SF, Eacker A, Moutier C, Satele DV, Sloan JA, Dyrbye LN. Distress Among Matriculating Medical Students Relative to the General Population. Academic Medicine. Nov 2014; 89(11): 1520-1525. doi: 10.1097/ACM.0000000000000482

Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, West CP. Changes in Burnout and Satisfaction with Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc. Dec 2015;90(12):1600-13. doi: 10.1016/j.mayocp.2015.08.023.

CDEM Voice – FOAMonthly




With Match behind us, we are entering the last quarter of the academic year. Many will reflect on the progress of graduating medical students and residents and anticipate the arrival of new medical students and interns. Along with that reflection and anticipation, medical schools are likely to be delivering end-of-course evaluations. An article by Dr. Maryellen Weimer on the website Faculty Focus entitled What Can We Learn from End-of-Course Evaluations? discusses how to use end-of-course evaluations to improve the quality of your teaching and your students’ learning.

First, mindset is important. End-of-course evaluations should be viewed as an opportunity for improvement; regardless of how good (or bad) the scores, there is always an opportunity to improve the learning experiences for students. Next, be curious. Use global ratings to ask yourself questions about your teaching style and why it is or is not effective for your learners. The article references the Teaching Perspectives Inventory ( which is helpful in providing information about your instructional strategies and can also provide useful insights for Educator Portfolios and educational philosophy statements. Finally, we need to be specific and timely in the feedback we request from our students. The start-stop-continue method has been shown to improve the quality of student feedback. Ask students what you should start doing, stop doing, and continue doing. Course directors can also share their interpretations of the feedback and develop an action plan for change and quality monitoring. End-of-course evaluations no longer need to evoke a sense of dread!


Kendra Parekh, MD


CDEM Faculty Podcast Episode 4

CDEM Faculty Podcast Episode 4:  Faculty Development  101 by Dimitri Papanagnou, MD, Sidney Kimmel Medical College

This first lecture from the Philadelphia EM Collaborative Faculty Development Program in Medical Education by Dr. Dimitri Papanagnou is an inspiring and motivating talk for those of us who are struggling to find our niche in emergency medicine.  I hope you enjoy it as much as I did!


Keep up to date on the latest CDEM Faculty podcast on SoundCloud, RSS, and iTunes.


Suzana Tsao, DO

Director Medical Student Clerkship

Perelman School of Medicine

CDEM Faculty Podcast Episode 3

CDEM Faculty Podcast Episode 3:  Philadelphia EM Collaborative Faculty Development Program in Medical Education

The Philadelphia Education Collaborative held its first conference this past October at Temple University’s Lewis Katz School of Medicine.  They graciously allowed me to record and share these amazing lectures with you all.  This first podcast is an interview with the creators:  David A. Wald, DO (Lewis Katz School of Medicine),  Dimitri Papanagnou, MD (Sidney Kimmel Medical College), and Francis DeRoos, MD (Perelman School of Medicine). 

Keep up to date on the latest CDEM Faculty podcast on SoundCloud, RSS, and iTunes.  


Suzana Tsao, DO

Director Medical Student Clerkship

Perelman School of Medicine

CDEM Voice – Research Column



How to appropriately analyze a Likert scale in medical education research


A common tool in both medical education and medical education research is the Likert scale.  The Likert scale is an ordinal scale using 5 or 7 levels. Despite regular use of the scale, its interpretation and statistical analysis continues to be a source of controversy and consternation.  While the Likert scale is a numerically based scale, it is not a continuous variable, but rather an ordinal variable. The question is then how to correctly analyze the data.

In the strictest sense ordinal data should be analyzed using non-parametric tests, as the assumptions necessary for parametric testing are not necessarily true.  Often investigators and readers are more familiar with parametric methods and comfortable with the associated descriptive statistics which may lead to their inappropriate use.  Mean and standard deviation are invalid descriptive statistics for ordinal scales, as are parametric analyses based on a normal distribution.  Non-parametric statistics do not require a normal distribution and are therefore always appropriate for ordinal data. Common examples of parametric tests are the t-test, ANOVA, and Pearson correlation.  Common examples of corresponding non-parametric tests the Wilcoxon Rank Sum, Kruskal Wallis Test, and Spearman Correlation.

The confusion and controversy arise because parametric testing may be appropriate and in fact more powerful than non-parametric testing of ordinal data provided certain conditions exist.  Parametric tests require certain assumptions such as normally distributed data, equal variance in the population, linearity, and independence.  If these assumptions are violated then a parametric statistic cannot be applied. Care must also be taken to ensure that averaging the data isn’t misleading.  This can occur if the data is clustered at the extremes resulting in a neutral average. For instance, if we used a Likert scale to evaluate the current polarized political climate, we would likely be clustered at the extremes, yet the mean might lead us to believe everyone is neutral.

Frequently, the responses on a Likert scale are averaged and the means are compared between the control and intervention group (or before and after implementation of an educational tool) utilizing a T-test or ANOVA.  While these are the correct statistical analyzes for comparing means, one cannot calculate an actual mean for a Likert scale as it is not a continuous numerical value and the distance between values may not be equal therefore it is also not interval data.  For example, in a study comparing mean arterial blood pressures between an experimental drug and placebo, there is a continuous numerical variable for a mean can be calculated between the two study groups. In contrast for a Likert scale of 1-5, these are ordinal classifications and there are no responses of 1.1, 2.7, 3.4 or 4.2. Therefore, a mean of 3.42 for the control group and 3.86 for the intervention group does not fall within the pre-defined ordinal category responses of the Likert scale.

One approach is to dichotomize the data into “yes” and “no” categories.  For example, on a scale from 1-5 with 3 being “average” one could group responses into >3 or <3.  Dichotomizing the data is also a mechanism to increase the power. An exception to this is if one is using a series of questions and averaging the individual’s response to create a single composite score and then compares the composite scores across the groups. Under this scenario, comparing means may be appropriate since the data has been converted into a continuous variable.

After dichotomizing, one can utilize a Fisher’s exact or a Chi-Squared test to analyze the data.  Stay tuned for a future explanation of the differences between and Fisher’s exact and Chi-Squared analysis!

Understanding the statistics can help improve the experimental design and avoid inappropriate application of statistical analyses yielding erroneous conclusions.


Jason J. Lewis, MD    &    David Schoenfeld, MD, MPH

Beth Israel Deaconess Medical Center/Harvard Medical School


Boone, H.N. and Boone, D.A. (2012, April). Analyzing Likert Data. Retrieved from: Accessed February 16, 2017.

CDEM VOICE – Committee Update



The NBME EM Advanced Clinical Examination Task Force was formed in 2011.  The task force is made up of CDEM members who are current or previous clerkship directors along with NBME staff.  The task force was charged with the development of an EM Advanced Clinical Examination (ACE).  The task force has been responsible for developing the test blueprint, finalizing the test content and assigning appropriate weights to specific categories of disease across various physician tasks.  Task Force members have also been responsible for generating new items to fill gaps in the test question pool.  To date, members have written and reviewed many hundreds of questions.  The EM ACE was first made available in April 2013.  Although the test is designed as a knowledge base assessment for students completing a required 4th year clerkship in EM, the test is also taken by many 3rd year students.  In the 2015 – 2016 academic year, almost 5,000 medical students across the country completed the examination (4th year students; n-3,752, 3rd year students; n-995).

This past year, the task force, working with the NBME conducted a web-based study to establish grading guidelines for the EM ACE.  Medical school faculty representing 27 different institutions participated in this study.   The task force has published multiple abstracts regarding the EM ACE examination.  We continue to meet on an annual basis and are currently collaborating with the NBME on a number of research initiatives.

  1. Miller ES, Wald DA, Hiller K, Askew K, Fisher J, Franzen D, Heitz C, Lawson L, Lotfipour S, McEwen J, Ross L, Baker G, Morales A, Butler A. Initial Usage of the National Board of Medical Examiners Emergency Medicine Advanced Clinical Examination.  Acad Emerg Med. 2015;22:s14.
  2. Miller ES, Wald DA, Hiller K, Askew K, Fisher J, Franzen D, Heitz C, Lawson L,    Lotfipour S, McEwen J, Ross L, Baker G, Morales A, Butler A. National Board of Emergency Medicine Advanced Clinical Examination 2014 Post-Examination Survey Results. Acad Emerg Med. 2015;22:s109.
  3. Fisher J, Wald DA, Orr N, et al.  National Board of Medical Examiners’ Development of an Advanced Clinical Examination in Emergency Medicine.  Ann Emerg Med. 2012;60:s190-191.
  4. Ross L, Wald DA, Miller ES, et al.  Developing Grading Guidelines for the NBME® Emergency Medicine Advanced Clinical Examination.  Accepted for publication West J Emerg Med 2017.

David A. Wald, DO

On behalf of the NBME EM ACE Task Force

David Wald
o    David A. Wald
o    Doug Franzen
o    Jonathan Fisher
o    Kathy Hiller
o    Emily Miller
o    Luan Lawson
o    Kim Askew
o    Jules Jung
o    Cory Heitz
Prior Members:
o    Shahram Lotfipour
o    Jill McEwen

CDEM Voice – Member Highlight



Sharon Bord MD, FACEP

Assistant Professor

Associate Director, Medical Student Education

Department of Emergency Medicine

The Johns Hopkins University School of Medicine

  1. What is your most memorable moment of teaching?

I would say that teaching is about lots of little moments, rather than one big memorable moment. From the thank you at the end of a shift from a student who is on their first rotation to sharing Match Day envelope opening with students who I have advised to seeing students years after they graduated at conferences presenting an abstract or giving a presentation. Putting all of these experiences together make my job worthwhile.

  1. Who or what is your biggest influence?

I think that my kids are my biggest influence. I have two girls, ages 4 and 6 and ultimately I want to be a wonderful role model for them. I want to teach them that they can do anything they want with their lives and to dream big. It is sometimes silhouette1hard because with our job we can miss out on weekends, holidays and other special occasions, but they are starting to understand the importance of what I do and why I do it, and I think that this will only continue to grow over the years.

  1. Any advice for other clerkship directors?

Over the years I have learned to listen to the students. They generally have their finger on the pulse of the medical school and have the best understanding of how the different clerkship experiences compare to one another. Also, keep things fun and interactive! My goal is to get people excited about Emergency Medicine- who knows when a student will be in a position to save someone’s life. I want them to feel empowered and prepared to act quickly.

  1. What is your favorite part about being and educator/director?

My favorite part about being an educator is giving back. Being an educator is more than just reaching students on their clerkship. It involves teaching nurses, physician assistants and patients. To me it means setting a strong and positive example for those around me. And then, at the end of a shift or encounter receiving a genuine thank you- it can really make your day!

  1. Any interesting factoids you would like to share?

I got accepted into medical school off the wait list on August 8th- just 2 weeks before it was starting. Throughout medical school I was one of the hardest working students, mainly because I felt I had something to prove. All that hard work paid off when I was inducted into AOA graduation week. Following medical school I went on to an amazing training program at Boston Medical Center, and now am working as an educator at The Johns Hopkins School of Medicine. I am just so thankful that someone took a chance on me that early August day and completely changed the trajectory of my life!

I tell students all the time, the hardest part is getting into medical school!