AEM Education and Training 07: Virtual Reality as an Interview Technique for EM Applicants

Welcome to the seventh episode of AEM Education and Training, a podcast collaboration between the Academic Emergency Medicine E&T Journal and Brown Emergency Medicine. Each quarter, we'll give you digital open access to AEM E&T Articles or Articles in Press, with an author interview podcast and links to curated supportive educational materials for EM learners and medical educators.

Find this podcast series on iTunes here.

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DISCUSSING (click on title to access):

Virtual Reality as an Interview Technique in Evaluation of Emergency Medicine Applicants. Scott B. Crawford, MD, Stormy M. Monks, PhD, MPH, and Radosveta N. Wells, MD

LISTEN NOW: AUTHOR INTERVIEW WITH SCOTT CRAWFORD, MD

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Scott Crawford, MD

Department of Emergency Medicine

Department of Emergency Medicine, Texas Tech University Health Science Center El Paso

ARTICLE ABSTRACT:

Need for Innovation
Current interviewing strategies and the standardized letter of evaluation may not provide enough insight into preferred resident characteristics. Emergency medicine (EM) residency programs are challenged with identifying trainees who can problem solve, communicate, and work well with fellow health professionals.

Background
Structured interviews have previously been used and can help predict success but candidates have reported a negative impression with their use.

Objective of Innovation
This structured virtual reality (VR) interviewing method was designed so that interviewers can observe the communication abilities, subtle personality traits, and teamwork skills of applicants interviewed at an EM residency program.

Development Process
A consumer VR headset became available and in combination with an interactive team game was incorporated into a standardized team‐based interview session. This session was designed to allow observation of candidates’ communication, problem solving, and teamwork skills.

Implementation Phase
Surveys were collected to examine the satisfaction of EM residency applicants who participated in this novel standardized interviewing method using a VR headset. After the submission of rank lists, but prior to Match Day, those who interviewed were e‐mailed a voluntary, anonymous, and confidential survey asking about their interview experience, specifically about the VR portion. The survey was sent to 102 applicants with 63 responses for a 62% response rate at the completion of the 2015 to 2016 interview season.

Outcomes
Overall study findings suggested that participants had a highly favorable impression of the VR portion of the interview. Specifically, participants reported that this interview technique was appropriate and worthwhile. Additionally, participants attested that the Oculus portion of the interview gave insight to their work ethic, personality, and communication skills and how they work with others.

Reflective Discussion
The novel interviewing method used in this study allowed interviewers to gain insight beyond that of the paperwork and brief face‐to‐face interaction. Study findings suggest that interviewees accepted the use of this novel interview method. It has been incorporated into our interview process for three consecutive years.

 

Money Minutes for Doctors #6 - The IRA

Welcome to the sixth edition of the Money Minutes for Doctors podcast! In this edition we discuss the IRA. Chances are you have heard of the "individual retirement account", but what does it really mean and how does it affect your retirement strategy? This month Ms. Katherine Vessenes, JD, CFP®, RFC, Founder and President of MD Financial Advisors, discusses the benefits of the IRA, how to choose the right type of IRA for you, and how to utilize it for tax efficient investing. 

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About Ms. Vessenes:

Ms. Vessenes works with over 300 physicians and dentists from Hawaii to Cape Cod. Her firm uses a team of experts to provide comprehensive financial planning to help doctors build their wealth and protect their wealth while reducing taxes now and in the future. Katherine is a longtime advocate for ethics in the financial services industry; and has written three books on the subject of investment strategies. She has received many honors and awards including: numerous tributes from Medical Economics as a top advisor for doctors, multiple 5-Star Advisor Awards, honored as a Top Woman in Finance, in addition to being selected to be on the CFP® Board of Ethics. Katherine can be reached at: Katherine@mdfinancialadvisors.com or 952-388-6317. Her website: www.mdfinancialadvisors.com.

Quick Summary:

IRAs first became available in 1975 as a way for Americans to save money for retirement in a tax deferred way.

IRA Basics:

1.    You, or your spouse, must be working in order to contribute.

2.    Your contribution is limited to the amount of your earned income or the annual limits, whichever is lower.

a.    In 2018 the amount is $5,500 for doctors < 50, and $6,500 for 50+

b.    Amount is increased periodically to keep up with inflation.

3.    Once you reach the age of 70 1/2, you are no longer eligible to make an IRA contribution even if you are working

4.    Some Americans can deduct the amount they contribute to an IRA from their taxable income if they do not have retirement plans at work and their income is below a threshold. Currently the threshold is $189,000 in modified adjusted gross income, if one spouse has a plan at work and the other one doesn’t

5.    IRA accounts are held at custodians. This could be a bank, like Bank of America or Wells Fargo, or an investment company/brokerage firm like Fidelity, Vanguard, or TD Ameritrade, to name just a few.

6.    You are able to select any investments that your custodian offers. Common investment options include basic cash or money market accounts, annuities, stocks, bonds, mutual funds and real estate funds

7.    Transactions in the IRA, including any interest on the bonds, dividends on the stocks or capital gains, are not subject to any tax while still in the account. However, once you start making withdrawals from the account, you will owe both Federal and State Tax (if your state charges a state tax) on the withdrawals.

8.    You can have more than one IRA account and it is not unusual for us to see doctors with numerous ones held at different institutions.

a.    Usually it is best to combine all of your IRAs into one account and use a consistent investment philosophy on all your investments.

9.    Once you are 70 ½, you are required to start taking withdrawals from your IRA and pay tax on them.

a.    The RMD is set by statue and increases as you get older.

b.    Large penalties (50%)for failing to make these withdrawals

10.  Can do rollover from an “old” 401-k or 403-b (usually from prior employers) into an IRA.

a.    This is not a taxable event.

b.    Almost always recommended b/c (1) usually have better investment options in your own IRA (2) usually have lower fees and (3)helps consolidate your investments making them easier to manage.

As with any investment, there are pros and cons to using an IRA. Here are a few items all physicians and dentists should consider before using these vehicles.


PROS

1.    The earnings or growth inside the IRA are not taxable until withdrawn.

2.    An IRA is protected from creditors, which is an important consideration for our doctors who are concerned about asset protection strategies. The levels of the protection vary from state to state.

3.    Current IRS rules allow you to convert an unlimited amount of funds in your IRAs to Roth IRAs.

CONS:

1.    Withdrawals are subject to ordinary income tax rates in the year of distribution, on the entire amount of the distribution.

2.    IRAs cannot be used as collateral for a loan.

3.    You cannot borrow from an IRA. If you do, it is considered a taxable event.

4.    The size of an IRA account may mislead some doctors into thinking they are far wealthier than they really are but remember you still need to pay taxes on this money!

5.    There are major penalties if you pull the funds out before 59 ½: There are some nuances so use a rusted advisor to help you make these decisions.

6.    Leaving your IRA to your children or other individuals is not as generous as you may think due to tax liabilities!

7.    If you do convert your IRA to a Roth, the taxes may have to come from another account if you are under the age of 59 ½. If you are over that age, you can deduct the taxes from the IRA as you convert.

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Takeaway: One thing doctors should notice from this article is: this simple retirement tool, is anything but simple. If you are a doctor who has an IRA or is considering investing in one, we recommend getting good, solid advice from an experienced expert, and I don’t mean calling the help desk at your custodian! Those help-desk folks are usually kind, dedicated individuals, but they haven’t had the training necessary to give a doctor the kind of advice they need for a complex situation.

AEM Early Access 18: The YEARS Criteria in Evaluating PE

Welcome to the eighteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

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DISCUSSING (OPEN ACCESS THROUGH SEPTEMBER 30, 2018; CLICK ON TITLE TO ACCESS):

Multicenter Evaluation of the YEARS Criteria in Emergency Department Patients Evaluated for Pulmonary Embolism. Christopher Kabrhel MD,MPH  Astrid Van Hylckama Vlieg PhD  Alona Muzikanski MS Adam Singer MD  Gregory J. Fermann MD  Samuel Francis MD  Alex Lim kakeng MD Ann Marie Chang MD  Nicholas Giordano MA  Blair Parry BA.

LISTEN NOW: INTERVIEW WITH LEAD AUTHOR DR. KABRHEL:

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Christopher Kabrhel MD, MPH

Associate Professor, Harvard Medical School

Director, Center for Vascular Emergencies

Department of Emergency Medicine

Massachusetts General Hospital

ABSTRACT:

Background
It may be possible to safely rule out pulmonary embolism (PE) in patients with low pre‐test probability (PTP) using a higher than standard D‐dimer threshold. The YEARS criteria, which includes three questions from the Wells PE Score to identify low PTP patients and a variable D‐dimer threshold, was recently shown to decrease the need for imaging to rule out PE by 14% in a multicenter study in the Netherlands. However, the YEARS approach has not been studied in the United States.

Methods
Prospective, observational study of consecutive adult patients evaluated for PE in 17 U.S. emergency departments. Prior to diagnostic testing, we collected the YEARS criteria: “Does the patient have clinical signs or symptoms of DVT?”, “Does the patient have hemoptysis?”, “Are alternative diagnoses less likely than PE?” with YEARS (+) being any “yes” response. A negative D‐dimer was <1000 mg/dL for YEARS (‐) patients, and <500 mg/dL for YEARS (+) patients. We calculated test characteristics and used Fisher's exact test to compare proportions of patients who would have been referred for imaging and patients who would have had PE “missed.”.

Results
Of 1789 patients, 84 (4%) had PE, 1134 (63%) were female, 1038 (58%) were White and mean age was 48 years. Using the standard D‐dimer threshold, 940 (53%) would not have had imaging, with 2 (0.2%, 95% CI: 0.02%, 0.60% “missed” PE. Using YEARS adjustment, 1204 (67%, 95% CI: 65%, 69%) would not have been referred for imaging, with 6 (0.5%, 95% CI: 0.18%, 1.1%) “missed” PE, and using “alternative diagnoses less likely than PE” adjustment, 1237 (69%, 95% CI: 67%, 71%) would not have had imaging with 6 (0.49%, 95% CI: 0.18%, 1.05%) “missed” PE. Sensitivity was 97.6% (95% CI: 91.7%‐99.7%) for the standard threshold, and 92.9% (95% CI: 85%‐97%) for both adjusted thresholds. NPV was nearly 100% for all approaches.

Conclusions
D‐dimer adjustment based on pre‐test probability may result in a reduced need for imaging to evaluate possible PE, with some additional “missed” PE but no decrease in NPV.