The Effect of Emergency Medicine Residents on Clinical Efficiency and Staffing Requirements

Objectives

The effect of emergency medicine (EM) residents on the clinical efficiency of attending physicians is controversial. The authors hypothesized that implementing a new EM residency program would result in an increase in relative value units (RVUs) generated per hour by attending physicians and decrease staffing requirements.

Methods

This was a retrospective observational analysis of an emergency department before, during, and after the establishment of a new EM residency program. We analyzed the change in RVUs billed, patients seen, and hours worked by attending physicians, midlevel providers (MLPs), and residents, and addressed potential confounding factors.

Results

The clinical efficiency of attending physicians increased by 70%, or 4.98 RVUs/hour (from 7.12 [SD ± 1.4] RVUs/hour to 12.1 [SD ± 2.2] RVUs/hour, p < 0.001) with the implementation of an EM residency program. Overall, net department RVU generation rose by 32%, even as attending physician coverage decreased by 6.3% (p < 0.05), and MLP coverage dropped by 60% (p < 0.05). We estimated that the implementation of the residency saved 4,860 hours of attending physician coverage and 5,828 hours of MLP coverage per year. This represents an estimated $1,741,265 in annual staffing savings, comparable to the residency program's annual operating cost of $1,821,108.

Conclusions

The implementation of an EM residency program had a positive effect on the clinical efficiency of attending physicians and decreased staffing requirements.     

Faculty Evaluation by Residents in an Emergency Medicine Program: A New Evaluation Instrument

OBJECTIVE: Evaluation of preceptors in training programs is essential; however, little research has been performed in the setting of the emergency department (ED). The goal of this pilot study was to determine the validity and reliability of a faculty evaluation instrument-the Emergency Rotation (ER) scale-developed specifically for use in emergency medicine (EM). METHODS: A prospective study comparing the ER scale with two alternative faculty evaluation instruments was completed in three of the five EDs affiliated with an EM teaching program, where emergency physicians are members of the clinical teaching faculty. The participants were 18 residents (postgraduate years 1, 2, and 3) who were completing four-week clinical rotations in EM. Residents at the end of the rotation recorded their evaluations of each emergency physician with whom they had clinical encounters on the following evaluation tools: the ER scale, a longer validated scale (Irby), and a global assessment scale (GAS). Domain scores were correlated with the previously validated scale and the GAS to determine validity using a multitrait-multimethod matrix. The reliability of the ER scale was measured using a Chronbach's alpha coefficient. RESULTS: Forty-eight preceptor evaluations were completed on 29 individual preceptors. The rating of preceptors was high using the ER scale (median: 16 of 20; IQR: 13, 18), Irby (median: 300 of 378; IQR: 267, 321), or GAS (mean: 7.8 of 10; SD: 1.3). Domain scores for each tool were used in the multitrait-multimethod matrix and the correlations between a previously validated tool and the ER scale were found to be high (>0.70) in the various domains. The internal consistency of the ER scale was also high (r = 0.85). CONCLUSIONS: The ER scale appears to be valid and reliable. It performs well when compared with previously psychometrically tested tools. It is a sensible, well-adapted tool for the teaching environment offered by EM.     

Academic Emergency Medicine Staffing Nonacademic Emergency Department Sites: A National Survey

Changing health care markets have threatened academic health centers and their traditional focus on teaching and research. OBJECTIVES: To determine the number of academic emergency medicine departments (AEMDs) that staff additional non-academic ED sites and to determine whether clinical reimbursement monies from those ED sites are used for academic purposes. METHODS: A two-part survey of all 119 academic EM programs listed in the 1997-1998 Graduate Medical Education Directory was conducted. Questionnaires were addressed to each AEMD chair. AEMDs and ED sites were characterized. Hiring difficulties, EM faculty academic productivity, and use of ED site reimbursement monies for academic activities were assessed. RESULTS: Ninety-nine of 119 (83%) AEMDs responded. Twenty-three (23%) AEMDs staffed 28 added ED sites. These sites tended to be urban (65%), with moderate volumes (25,000-35,000 patients/year), and had an equal or better reimbursement rate than the AEMD (89%). ED sites were commonly staffed by academic EM faculty (79%) and EM residents (29%). Ninety-six percent of the AEMDs had hired additional faculty; hiring new faculty was considered easy. Academic productivity at AEMDs with added ED sites was reported as unchanged. Reimbursement monies from these ED sites were commonly used for faculty salary support, faculty development, and EM research and residency activities. CONCLUSIONS: Academic EM departments are often affiliated with nonacademic ED sites. These additional sites are commonly staffed by academic EM faculty and EM residents. Academic productivity does not appear to decrease when additional ED sites are added. Reimbursement monies from these ED sites commonly supports academic activities.     

Reliability of Faculty Clinical Evaluations of Non-Emergency Medicine Residents during Emergency Department Rotations

Objectives: To assess the reliability of faculty evaluations of non-emergency medicine (non-EM) residents during clinical ED rotations and to determine the effect that the “leniency” of grading by these evaluators had on the residents' final evaluations. Methods: A prospective, observational study of the evaluation patterns of EM faculty was performed in an academic ED (50, 000 visits yearly census). Each resident was evaluated on a daily basis by a board-certified or board-prepared emergency physician. The evaluation form rated 7 characteristics, but only the rating for overall clinical competence was used for data analysis. If an attending evaluated the same resident more than once, only the first evaluation was used to avoid bias from prior exposure. The scoring patterns of the evaluators, both individually and in groups, were analyzed using 1-way analysis of variance. Evaluator leniency was estimated using the mean evaluator score across all residents. Since each resident was evaluated by a different combination of evaluators, evaluator leniency for each resident was estimated from the mean leniency of the evaluators who specifically assessed that resident. Results: During the period of the study, 66 residents rotated through the ED, yielding a total of 401 evaluations. When the scoring patterns of individual evaluators were analyzed, a high degree of variability was found in the mean scores (range 5.23–8.09) and SDs (range 0.45–1.55) across evaluators; p = 0.0001. There was a moderate correlation between the mean overall competence score received by each resident and that resident's evaluators' leniency, r = 0.52; p = 0.0001. Conclusions: There is significant variability in the scoring patterns of individual evaluators. The evaluators in this study showed large variations in both leniency (as measured by their mean score) and range restriction (as measured by their SD). The differences in evaluator scoring leniency have a moderate correlation with the overall score received by the resident.     

Pilot Study: Concordance of Disposition for Hypothetical Medical Patients in the Emergency Department

Objectives: Emergency physicians (EPs) make dispositions for every patient in the emergency department (ED) and often require agreement from inpatient services to admit medical patients to the hospital. Sometimes disagreements arise. The authors sought to determine in their institution disposition concordance between EPs and admitting medical services of hypothetical ED patients. A second objective was to describe additional information requested by each service. Methods: Within a two‐week period, physicians from emergency medicine (EM), family practice (FP), and internal medicine (IM) voluntarily completed anonymous questionnaires asking them to disposition hypothetical ED patients. Eleven case scenarios were followed by three disposition choices (admit, discharge, or cannot tell) from given information (followed by a free‐text area). Results: A total of 105 questionnaires were returned: 42 from EM (12 attending physicians/30 residents), 33 from FP (14 attending physicians/19 residents), and 30 from IM (4 attending physicians/26 residents). Admission rates were statistically different for EM (68% attending physicians/65% residents/66% total) when compared with FP (42% attending physicians/54% residents/49% total) (p < 0.01) and IM (36% attending physicians/53% residents/51% total) (p < 0.01). Discharge rates were also statistically different for EM (8% attending physicians/19% residents/16% total) versus FP (29% attending physicians/29% residents/28% total) (p < 0.01) and IM (27% attending physicians/28% residents/28% total) (p < 0.01). “Cannot tell” rates were not significantly different between groups (p > 0.05) for EM (23% attending physicians/16% residents/18% total) versus FP (25% attending physicians/14% residents/19% total) and IM (36% attending physicians/16% residents/18% total). The proportion of additional tests requested in the “cannot tell” disposition by attending EPs was about half that of the other groups. Dispositions between FP and IM were not different at any level (p > 0.05). Conclusions: In the authors' institution, when presented with identical hypothetical ED patients, EPs would admit more, discharge less, and ask for fewer additional tests than FP or IM physicians. The FP and IM physicians surveyed disposition patients in a similar manner.     

RVU Ready? Preparing Emergency Medicine Resident Physicians in Documentation for an Incentive‐based Work Environment

Objectives:  The emergency medicine (EM) job market is increasingly focused on incentive-based reimbursement, which is largely based on relative value units (RVUs) and is directly related to documentation of patient care. Previous studies have shown a need to improve resident education in documentation. The authors created a focused educational intervention on billing and documentation practices to meet this identified need. The hypothesis of this study was that this educational intervention would result in an increase in RVUs generated by EM resident physicians and the average amount billed per patient.
Methods:  The authors used a quasi-experimental study design. An educational intervention included a 1-hour lecture on documentation and billing, biweekly newsletters, and case-specific feedback from the billing department for EM resident physicians. RVUs and charges generated per patient were recorded for all second- and third-year resident physicians for a 3-month period prior to the educational intervention and for a 3-month period following the intervention. Pre- and postintervention data were compared using Student's t-test and repeated-measures analysis of variance, as appropriate.
Results:  The evaluation and management (E/M) chart levels billed during each phase of the study were significantly different (p < 0.0001). The total number of RVUs generated per hour increased from 3.17 in the first phase to 3.71 in the second phase (p = 0.0001). During the initial 3-month phase, the average amount billed per patient seen by a second- or third-year resident was $282.82, which increased to $301.94 in the second phase (p = 0.0004).
Conclusions:  The educational intervention positively affected resident documentation resulting in greater RVUs/hour and greater billing performance in the study emergency department (ED).     

Cost of an Acting Intern: Clinical Productivity in the Academic Emergency Department

Background

A few studies suggest that an increasing clinical workload does not adversely affect quality of teaching in the Emergency Department (ED); however, the impact of clinical teaching on productivity is unknown.

Objectives

The primary objective of this study was to determine whether there was a difference in relative value units (RVUs) billed by faculty members when an acting internship (AI) student is on shift. Secondary objectives include comparing RVUs billed by individual faculty members and in different locations.

Methods

A matched case-control study design was employed, comparing the RVUs generated during shifts with an Emergency Medicine (EM) AI (cases) to shifts without an AI (controls). Case shifts were matched with control shifts for individual faculty member, time (day, swing, night), location, and, whenever possible, day of the week. Outcome measures were gross, procedural, and critical care RVUs.

Results

There were 140 shifts worked by AI students during the study period; 18 were unmatchable, and 21 were night shifts that crossed two dates of service and were not included. There were 101 well-matched shift pairs retained for analysis. Gross, procedural, and critical care RVUs billed did not differ significantly in case vs. control shifts (53.60 vs. 53.47, p = 0.95; 4.30 vs. 4.27, p = 0.96; 3.36 vs. 3.41, respectively, p = 0.94). This effect was consistent across sites and for all faculty members.

Conclusions

An AI student had no adverse effect on overall, procedural, or critical care clinical billing in the academic ED. When matched with experienced educators, career-bound fourth-year students do not detract from clinical productivity.     

An Assessment of the Faculty Development Needs of Junior Clinical Faculty in Emergency Medicine

Objectives: Academic physicians must be able to access the resources necessary to support their ongoing professional development and meet requirements for continued academic advancement. The authors sought to determine the self‐perceived career development needs of junior clinical faculty in emergency medicine (EM) and the availability of educational resources to meet those needs. Methods: An educational “needs assessment” survey was distributed to 954 American College of Emergency Physicians (ACEP) members listed in the ACEP database as being faculty at EM residency programs in the United States and having graduated from an EM residency within the past 7 years. Respondents were asked to rank the importance of 22 areas of faculty development to their own professional growth and then to indicate whether educational resources in each area were available to them. Respondents were also asked to note the educational formats they prefer. A search for currently available resources in each topic area was undertaken and compared to the survey results. Results: A total of 240 responses were received. Self‐perceived career development needs were identified in the following areas: bedside teaching, lecture development, business skills, managerial skills, educational research, mentorship and career counseling, interpersonal skills, leadership skills, scholarly writing skills, physician wellness, and knowledge of the faculty development process. While a review of currently available educational resources revealed lectures, conferences, and online materials pertinent to most of these topics, a relative lack of resources in the areas of mentorship and physician wellness was identified. Conclusions: Junior clinical faculty in EM perceive a lack of educational resources in a number of areas of faculty development. The academic community of EM should strive to improve awareness of and access to currently existing resources and to develop additional resources to address the area of physician wellness. The lack of mentorship in academic EM continues to be a problem in search of a solution. ACADEMIC EMERGENCY MEDICINE 2008; 15:1–5 © 2008 by the Society for Academic Emergency Medicine     

Resident Evaluation of Clinical Teachers Based on Teachers'' Certification

OBJECTIVE: To examine the influence of emergency medicine (EM) certification of clinical teaching faculty on evaluations provided by residents. METHODS: A prospective cohort analysis was conducted of assessments between July 1994 and July 2000 on residents' evaluations of EM faculty at the University of Alberta, Edmonton, Canada. Resident- and faculty-related variables were entered anonymously using the validated evaluation tool (ER Scale). Credentialing and demographic information on EM faculty was supplemented by data obtained through a nine-question survey. Groups were compared using ANOVA. RESULTS: The 562 residents returned 705 (91%) valid evaluation sheets on 115 EM faculty members. The four domains of didactic teaching, clinical teaching, approachability, and helpfulness were assessed. The majority of ratings were in the very good or superb categories for each domain. Instructors with certification in EM had higher scores in didactic, clinical teaching compared with others, and teachers without national certification scored lower in the helpful and approachable categories (p < 0.05). The route of obtaining EM certifications either through training or practice eligibility did not affect scores. Instructors under the age of 40 years had higher scores than the older age groups in three of four categories (p < 0.05). Instructors working at the teaching sites on a half-time basis received higher scores than those working full-time, and scores varied based on site. Overall, teaching ratings improved over the study period (p < 0.05). CONCLUSIONS: Significant differences exist among instructors in the EM setting that affect their teaching rating scores. National certification in EM, academic track, rotation year, and site are all correlated with better teaching performance.     

Developing a Valid Evaluation for Interpersonal and Communication Skills

Objectives The Accreditation Council for Graduate Medical Education requires that residency programs evaluate the acquisition of six general competencies, including Interpersonal and Communication Skills (ICS). To develop a 360-degree method for accomplishing this, a semantic-differentiation matrix for various communication traits for nurses to evaluate physician ICS was developed. The authors sought to determine whether this evaluation method could discriminate between more experienced medical communicators (faculty) and less experienced medical communicators (residents).
Methods A 98-item questionnaire measured several communication dimensions by using an eight-element semantic-differentiation scale. In addition, global assessment ratings assessed nursing perceptions of physician ICS skills. This process was repeated for various clinical scenarios.
Results There were 26 nurse evaluators, 19 emergency medicine (EM) residents (EM2 and EM3), and 30 EM faculty. Each physician received five independent evaluations (total, 245 evaluations). All EM residents (EM2 and EM3) were compared with the EM faculty. All eight items on the semantic-differentiation scale were compared. Likewise, the global assessment scores were compared. In every category, the faculty scored higher (Mann-Whitney U: p < 0.001).
Conclusions An evaluation process integrating a semantic-differentiation matrix was applied to various clinical scenarios (as well as global assessment items) and demonstrated discriminatory results. Faculty physicians scored significantly higher than resident physicians. The ability to provide discriminatory results is a requisite in the development of a valid evaluation process. The described semantic-differentiation matrix and global assessment questions may be valid measurements of ICS.     

The Effects of Clinical Workload on Teaching in the Emergency Department

Background: Academic emergency physicians have expressed concern that increased clinical workload and overcrowding adversely affect clinical teaching. Objectives: To evaluate the influence of clinical workload and attending physicians' teaching characteristics on clinical teaching in the emergency department (ED). Methods: This was a prospective observational study using learner satisfaction assessment tools to evaluate bedside teaching. On days when a research assistant was available, all ED residents and attending physicians were queried. A total of 335 resident surveys were administered over nine months (89% response). Clinical workload was measured by perception and patient volume. Teaching quality and characteristics were rated on ten‐point scales. A linear mixed‐effects model was used to obtain adjusted impact estimates of clinical workload and teaching attributes on teaching scores while controlling for individual attending physicians' teaching ability and residents' grading tendencies. Results: No clinical workload parameter had a significant effect on teaching scores: residents' workload perception (β estimate, 0.024; p = 0.55), attending physicians' workload perception (β estimate, ?0.05; p = 0.28), patient volume in patients per hour (β estimate, ?0.010; p = 0.36), and shift type (β estimate, ?0.19; p = 0.28). The individual attending physician effect was significant (p < 0.001) and adjusted in each case. In another model, the attending physicians' learning environment established (β estimate, 0.12; p = 0.005), clinical teaching skills (β estimate, 0.36; p < 0.001), willingness to teach (β estimate, 0.25; p < 0.001), and interpersonal skills (β estimate, 0.19; p < 0.001) affected teaching scores, but the attending physicians' availability to teach had no significant effect (β estimate, 0.007; p = 0.35). Conclusions: Clinical workload and attending physicians' availability had little effect on teaching scores. Attending physicians' clinical teaching skills, willingness to teach, interpersonal skills, and learning environment established were the important determinants of overall scores. Skilled instructors received higher scores, regardless of how busy they were.     

Evaluation of Emergency Medicine Resident Death Notification Skills by Direct Observation

Emergency physicians commonly perform death notifications. Physician training in death notification has been limited. Resident physicians are rarely evaluated in their performance of death notifications. OBJECTIVE: To evaluate death notification skills by direct observation of actual notifications performed by trained emergency medicine (EM) residents. METHODS: This was a prospective, observational study of EM resident death notification performance. EM residents received training and then were directly observed and evaluated by trained evaluators during actual death notifications in a 64,000-visit community teaching hospital emergency department. RESULTS: There were 327 evaluations of 70 different EM residents. Overall performance evaluations were 55% excellent, 40% satisfactory, and 5% unsatisfactory. Third-year EM residents and female EM residents were more likely to be rated excellent. CONCLUSIONS: Death notification is a skill that can be evaluated like other EM skills. Trained EM residents performed well in actual death notifications when directly observed and evaluated. Senior residents and female residents were more likely to be rated excellent.     

Evaluating the Effect of Emergency Residency Training on Productivity in the Emergency Department

Background

Resident productivity, defined as patients seen per unit time, is one measure that is used to assess the performance and educational progress of residents in the emergency department (ED). One published study suggested that emergency residency training (EM) does not improve productivity compared with that in other specialties, including internal medicine (IM).

Objectives

This study assesses how EM and IM trainees perform in the ED and illustrates how resident productivity changes through the academic year.

Methods

A retrospective review of attending physicians and residents working 8-h shifts in the higher acuity zone of a large-volume, tertiary, academic health care center was performed for July 2009, October 2009, January 2010, and April 2010. The total number of patients seen primarily and admitted during each shift was recorded. ED volume was approximated by the number of patients seen by the attending physician, and acuity was approximated by admission rate. A mixed model regression assessed the impact of year and type of residency training (e.g., EM1, EM2, IM1, and IM2), ED volume, and acuity on resident productivity (number of patients per shift). The study was granted waiver of informed consent by our institutional review board.

Results

We reviewed 936 shifts. After adjusting for acuity and ED volume, the EM1 group had a significant increase in patients per shift over the year, from 6.11 in July to 10.3 in April (p < 0.001). No other group increased productivity significantly.

Conclusions

The first EM training year leads to a significant change in productivity that separates EM from IM residents. This contradicts the previous assertion that non-EM residents have the same productivity as EM residents in the ED.     

A Case–based Emergency Medicine Curriculum for Senior Medical Students

Objective: To determine the effects of a case–based, core content–oriented emergency medicine (EM) curriculum on the basic EM knowledge of senior medical students.
Methods: All senior medical students rotating through the Milwaukee County EM elective during the 1992–1993 academic year were assigned specific chapter readings from a case–oriented EM textbook. A course curriculum consisting of goals and objectives for each chapter and two to three representative cases for the discussion topic also was distributed to each student. Interspersed with the cases was a series of questions directed at pathophysiology, diagnosis, management, and disposition. The EM faculty and residents conducted case discussions three times per week. AH students completing the rotation were given a pretest at the beginning and a final examination at the end of the rotation. In addition, the students rated the textbook, coursebook, and lecture series at the end of the rotation using a five–point Likert scale.
Results: Seventy–five students rotated through the elective. The students showed a significant improvement in their EM knowledge base as judged by improvement in final examination scores compared with pretest scores (pretest score 62.2 ± 7.1%; final examination score 76.2 ± 6.3%; p < 0.0001). The mean change in scores was 14.8%, with a range of –1.6% to 34%. The students also rated the textbook, coursebook, and lecture series as effective, as shown by high median scores on a Likert scale.
Conclusions: A case–based EM curriculum coupled with ED clinical experience improves basic EM diagnostic and management knowledge of senior medical students.     

8 The Observed Teaching Encounter: Providing Residents Feedback on Their Teaching Skills

Introduction:  Emergency medicine residents spend a significant portion of their time teaching junior residents and medical students in the clinical setting. Feedback is an integral component of any teaching curriculum, and therefore, feedback on residents' skill in teaching abilities is an essential part of their learning to teach. We have developed a structured method of providing feedback to senior residents on their teaching competence.
Methods:  Upcoming senior residents receive an 8-hour course on clinical teaching during their useful conference time. In our ED, attending faculty and senior "teaching" residents are matched with medical student learners. The Observed Teaching Encounter (OTE) is used during usual clinical ED shifts to reinforce concepts in teaching. During the OTE, the teaching resident is directly observed by a faculty physician while teaching a student learner. A checklist is completed by both the faculty member and the student learner in order to provide feedback to the teaching resident. Assessed skills correlate with teaching theory provided to residents in their didactic curriculum. Written formative comments are provided to the resident from faculty, as well.
Results:  Attending faculty, senior residents, and student learners have all provided positive feedback on the OTE. Assessment of residents' retention of knowledge on methodology of teaching is presently in progress as a tool to evaluate the efficacy of the OTE.     

Impact of Scribes on Performance Indicators in the Emergency Department

Objectives: The objective was to quantify the effect of scribes on three measures of emergency physician (EP) productivity in an adult emergency department (ED). Methods: For this retrospective study, 243 clinical shifts (of either 10 or 12 hours) worked by 13 EPs during an 18‐month period were selected for evaluation. Payroll data sheets were examined to determine whether these shifts were covered, uncovered, or partially covered (for less than 4 hours) by a scribe; partially covered shifts were grouped with uncovered shifts for analysis. Covered shifts were compared to uncovered shifts in a clustered design, by physician. Hierarchical linear models were used to study the association between percentage of patients with which a scribe was used during a shift and EP productivity as measured by patients per hour, relative value units (RVUs) per hour, and turnaround time (TAT) to discharge. Results: RVUs per hour increased by 0.24 units (95% confidence interval [CI] = 0.10 to 0.38, p = 0.0011) for every 10% increment in scribe usage during a shift. The number of patients per hour increased by 0.08 (95% CI = 0.04 to 0.12, p = 0.0024) for every 10% increment of scribe usage during a shift. TAT was not significantly associated with scribe use. These associations did not lose significance after accounting for physician assistant (PA) use. Conclusions: In this retrospective study, EP use of a scribe was associated with improved overall productivity as measured by patients treated per hour (Pt/hr) and RVU generated per hour by EPs, but not as measured by TAT to discharge. ACADEMIC EMERGENCY MEDICINE 2010; 17:490–494 © 2010 by the Society for Academic Emergency Medicine     

Impact of Emergency Medicine Faculty and an Airway Protocol on Airway Management

OBJECTIVE: To determine the impact of emergency medicine (EM) faculty presence and an airway management protocol on success rates of tracheal intubation in the emergency department (ED). METHODS: A retrospective observational study of prospectively collected data on rates of successful intubations between June 1997 and December 2001 in the ED of a large urban teaching hospital. The authors compared success rates of the first attempt at intubation and times to intubation prior to and after EM faculty presence and the institution of an airway management protocol. RESULTS: Prior to EM faculty presence and the airway management protocol, tracheal intubation was achieved on the first attempt 46% of the time; more than six attempts were required 2.9% of the time. The mean time to intubation was 9.2 minutes (+/-13.2 SD). Following EM faculty presence and the airway protocol, the success rate on the first attempt was 62%, more than six attempts were required 1.1% of the time, and the mean time to intubation was 4.6 minutes (+/-6.2 SD). CONCLUSIONS: First-attempt intubation success rates and decreased mean time to successful intubation improved following EM faculty presence and the introduction of an airway management protocol.     

University and Community Hospital Medical Student Emergency Medicine Clerkship Experiences

Objective : To determine whether there is a significant difference between educational opportunities for fourth-year medical students rotating at a university hospital (UH) compared with several community hospitals (CHs) during a mandatory emergency medicine (EM) clerkship.
Methods : A self-reported clinical tool was completed in real time by each student rotating for 2 weeks at the UH and 2 weeks at 1 of 4 CHs (3 affiliated and 1 unaffiliated). Students are required to document the number of patients seen and the number of procedures performed on each of 20 six-hour shifts. They rated the EM attending clinical teaching by site using a 5-point scale at the end of the clerkship.
Results : Most (95%) of the 87 students in the 7 clerkship blocks of the 1996–97 academic year rotated at the UH and a CH. Most (71%) students rated both the UH and the CH for the quality of teaching by attendings. There was a significant difference in the mean number of patients evaluated/shift (2.2 ± 0.10 vs 2.8 ± 0.10, UH vs CH; p < 0.001) and the mean number of procedures performed/shift (0.36 ± 0.04 vs 0.56 ± 0.05, UH vs CH; p < 0.001). Attending clinical teaching scores were significantly higher (p = 0.03) at the CHs.
Conclusions : The educational opportunities for students in an EM clerkship to evaluate patients and perform procedures were significantly greater at the community hospitals. Inclusion of community hospital settings in a medical student EM clerkship may optimize the clinical experience.