Objectives & Background During times of ED pressures training & CPD opportunities are often sacrificed, with conversations & emails focused on operational issues. Senior EM physicians continue to experience an interesting breadth of patients which was the foundation of their career choice. Senior EM physicians face clinical dilemmas and may not have ready opportunities to discuss, reflect and review their practice amongst peers. In Jan 2016 a remote senior EM peer CPD tool was introduced to allow impartial team review and reflection on a colleague's difficult clinical encounter. The tool has been welcomed and may be of interest to other EDs as an addition to their CPD

Methods The senior ED team submitted dilemmas to the project coordinator. A SurveyMonkey link, containing a description of two local ED dilemma with management option choices listed, was emailed to the senior ED team, with a request to vote for which one action they would have decided upon in that situation. A separate but identical survey was sent to senior trainees (ST3–6 ACP) and to ED consultants, to see any differences in responses. All responses were unidentifiable. A succinct analysis of results with graphs was emailed after 10 days, together with a brief summary of the realtime decision made and patient outcome

Results Typically surveys received responses from 9 consultants and 9 trainees. The remote online survey enabled flexible and more ready participation. Dilemma topics submitted were varied and included decisions around ceilings of care (ITU/palliation, CPR duration, elderly trauma), care without onsite specialist services (HI & raised ICP, acute aortic dissection & pericardial effusion), ECG interpretation, interactions with police. No scenario resulted in a unanimous vote of one most appropriate management choice, with splits of opinions ranging from 50:50 to 25:75. Trainee and consultant group responses were usually, but not always mirrored. The ability to compare practice against respected colleagues was assuring for the team, though the variety in responses also thought provoking

Conclusion ED physicians encounter situations without concrete guidance to fall upon and a best intention decision must be made. This tool is useful for reflection with colleagues, personal debrief and team's CPD. In addition, the survey results initiated enthusiastic discussions around the practice of emergency medicine which at times of ED pressures can be diluted.