ABC | Volume 114, Nº1, January 2019

Original Article Aimoli & Miranda STEMI Management by Recently Graduated Physicians Arq Bras Cardiol. 2020; 114(1):35-44 STEMI management. 5 A scenario of initial patient treatment in an emergency care unit (UPA) was set up. This scenario was designed both for research data collection and as one of the practical exam stations of the direct entry public selection process of the Ribeirão Preto Medical School Clinics Hospital of the University of São Paulo (HC-FMRP-USP), for admission of first-year residency physicians to different specialties, in 2016. The practical exam to which this study refers was performed only by the applicants approved in the first-stage written exam, consisting of multiple choice questions, at a rate of 4 candidates per vacancy (except for the Infectology and Neurosurgery fields, where the proportion was of 5 candidates per vacancy). A total 1,841 candidates applied for the first-stage exam, out of whom 1,622 performed the written exam (first stage), 863 applicants were approved for the practical exam (second stage) and 771 applicants actually took the practical exam in the STEMI station (Figure 1). The scenario organization Before beginning the treatment, the applicants were informed that they would assist an adult patient in a UPA. The scenario was organized as a standard doctor’s office, where a properly trained actor (Appendix B)* was lying on a stretcher and the evaluator was sitting at a table connected to a computer which displayed the checklist of predetermined competencies and attitudes. Inside the room, there was a printed instruction on the wall (Appendix A)* saying that the patient in question had been admitted with a complaint of chest pain, and that the nurse prioritized his care and traced a 12-lead ECG. An ECG with typical tracing for anterior wall STEMI was provided for the applicant (Appendix F)*. Some history and physical exam data were previously provided (severe retrosternal pain with an intensity 8/10 of sudden onset, associated with nausea, no irradiation and other associated symptoms, no other health problems, no use of medication in the previous 24 hours, physical examination revealed an oxygen saturation level of 98% on room air, a blood pressure of 130/80 mmHg and a heart rate of 88 bpm and no need for physical examination, considering the other data were normal). On the printed instructions, there were two tasks to be performed by the applicants: first, to define the main diagnosis for the evaluator; second, to provide the most adequate clinical management for the patient. The applicant was given a deadline of five minutes to execute these tasks. Time was clocked using an automated system. The actor was trained to ask the applicant two active questions in a row, only when the applicant suggested the need for a transfer to a hospital or Cardiology Center: “Doctor, why do I need to go to a hospital?”. And after 10 seconds: “Doctor, what if there is no room?”. In the consulting room, there was a list with all the medications and procedures available in that UPA (Appendix E)*, and there were no fibrinolytic therapy and coronary angioplasty available on site. A total of 11 simulated doctor offices were organized, which worked simultaneously during the evaluation. The evaluators’ training for filling out the checklist Sixteen evaluators, all experienced doctors, were trained to fill out the checklist electronically  , using a computer available in the scenario, simultaneously with the execution of the tasks by the applicants. The evaluators were instructed not to communicate with the applicants, who should only follow the written instructions. The instructions used in the evaluators’ training are available in Appendix C* of the supplementary appendix. Each applicant was evaluated by only one examiner. To reduce heterogeneity between the examiners a training was performed immediately before the beginning of the practical station, when each item of the checklist was reviewed in terms of possible answers. There was an external evaluator who was positioned in the access passage to all simulated consulting rooms and centralized any interpretation doubts concerning the applicants’ answers. This external evaluator’s opinion was always accepted in cases of doubtful interpretation on the part of the evaluators. Figure 1 – Flowchart with the number of applicants in the different phases of the medical residency selection process. 1,841 enrolled applicants 863 approved for the second phase 771 attended the practical exam 1,622 applicants attended the written exam 36