Observation Medicine in Emergency Medicine Residency Programs

OBJECTIVE: To evaluate observation unit (OU) prevalence, emergency medicine (EM) resident exposure in observation medicine (OM), EM faculty/residency director (RD) OM training, and RD attitudes toward OM. METHODS: Information was obtained from residency programs by telephone during a four-month period. RESULTS: Survey respondents indicated that 36.1% have OUs and 44.9% plan to have an OU. Observation medicine resources include textbooks 32.0%, articles 45.9%, lectures 36.9%, fellowships 2.5%, and research 26.2%. Observation medicine patient care occurs: 1) during residency: 25.4% of RDs, 11.3% of entire faculty; 2) as an attending: 45.1% of RDs. CONCLUSIONS: Nearly two-thirds of EM programs have or are planning an OU. Resources are lagging behind. This survey describes current OM education strategies to teach OM.     

The Status of Bedside Ultrasonography Training in Emergency Medicine Residency Programs

Bedside ultrasonography (BU) is rapidly being incorporated into emergency medicine (EM) training programs and clinical practice. In the past decade, several organizations in EM have issued position statements on the use of this technology. Program training content is currently driven by the recently published "Model of the Clinical Practice of Emergency Medicine," which includes BU as a necessary skill. OBJECTIVE: The authors sought to determine the current status of BU training in EM residency programs. METHODS: A survey was mailed in early 2001 to all 122 Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs. The survey instrument asked whether BU was currently being taught, how much didactic and hands-on training time was incorporated into the curriculum, and what specialty representation was present in the faculty instructors. In addition, questions concerning the type of tests performed, the number considered necessary for competency, the role of BU in clinical decision making, and the type of quality assurance program were included in the survey. RESULTS: A total of 96 out of 122 surveys were completed (response rate of 79%). Ninety-one EM programs (95% of respondents) reported they teach BU, either clinically and/or didactically, as part of their formal residency curriculum. Eighty-one (89%) respondents reported their residency program or primary hospital emergency department (ED) had a dedicated ultrasound machine. BU was performed most commonly for the following: the FAST scan (focused abdominal sonography for trauma, 79/87%); cardiac examination (for tamponade, pulseless electrical activity, etc., 65/71%); transabdominal (for intrauterine pregnancy, ectopic pregnancy, etc., 58/64%); and transvaginal (for intrauterine pregnancy, ectopic pregnancy, etc., 45/49%). One to ten hours of lecture on BU was provided in 43%, and one to ten hours of hands-on clinical instruction was provided in 48% of the EM programs. Emergency physicians were identified as the faculty most commonly involved in teaching BU to EM residents (86/95%). Sixty-one (69%) programs reported that EM faculty and/or residents made clinical decisions and patient dispositions based on the ED BU interpretation alone. Fourteen (19%) programs reported that no formal quality assurance program was in place. CONCLUSIONS: The majority of ACGME-accredited EM residency programs currently incorporate BU training as part of their curriculum. The majority of BU instruction is done by EM faculty. The most commonly performed BU study is the FAST scan. The didactic component and clinical time devoted to BU instruction are variable between programs. Further standardization of training requirements between programs may promote increasing standardization of BU in future EM practice.     

Graduate Medical Education Downsizing: Perceived Effects of Participating in the HCFA Demonstration Project in New York State

OBJECTIVE: Financial support for graduate medical education (GME) is shrinking nationally as Medicare cuts GME funds. Thirty-nine hospitals in New York State (NYS) voluntarily participated in a Health Care Financing Administration demonstration project (HCFADP)-the goal of which was to reduce total residency training positions by 4-5%/year over a five-year period, while increasing primary care positions. The objective of this study was to determine the effect of downsizing on emergency department (ED) staffing and emergency medicine (EM) residency training. METHODS: Structured interviews and surveys of NYS program directors (PDs) were conducted in October-December 1999. Simple frequencies are reported. RESULTS: One hundred percent of 17 PDs completed the interviews and seven of 12 participants in the HCFADP returned surveys. Twelve of 17 programs participated in HCFADP and two programs downsized outside HCFADP. Seven of 12 participants lost EM positions. Six of 12 programs were forced to exclude outside residents from rotating in their ED, leading to a need for one participating program and one non-participating program to find alternative sites for trauma. Five of 12 institutions provided resident staffing data, reporting a reduction in ED resident coverage in year 1 of the project of 9-40%. Programs compensated by increasing the number of shifts worked (4/12), increasing shift length (1/12), decreasing pediatric ED shifts (1/12), decreasing elective or research time (2/12), and decreasing off-service rotations (4/12). Six departments hired physician assistants or nurse practitioners, two hired faculty, and two hired resident moonlighters. Six of 12 programs withdrew from HCFADP and returned to previous resident numbers. Eight of 12 PDs thought that they had decreased time for clinical teaching. CONCLUSIONS: A 4-5% reduction in residency positions was associated with a marked reduction in ED resident staffing and EM residency curriculum changes.     

A Model Longitudinal Observation Medicine Curriculum for an Emergency Medicine Residency

The role of observation services for emergency department patients has increased in recent years. Driven by changing health care practices and evolving payer policies, many hospitals in the United States currently have or are developing an observation unit (OU) and emergency physicians are most often expected to manage patients in this setting. Yet, few residency programs dedicate a portion of their clinical curriculum to observation medicine. This knowledge set should be integrated into the core training curriculum of emergency physicians. Presented here is a model observation medicine longitudinal training curriculum, which can be integrated into an emergency medicine (EM) residency. It was developed by a consensus of content experts representing the observation medicine interest group and observation medicine section, respectively, from EM's two major specialty societies: the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP). The curriculum consists of didactic, clinical, and self‐directed elements. It is longitudinal, with learning objectives for each year of training, focusing initially on the basic principles of observation medicine and appropriate observation patient selection; moving to the management of various observation appropriate conditions; and then incorporating further concepts of OU management, billing, and administration. This curriculum is flexible and designed to be used in both academic and community EM training programs within the United States. Additionally, scholarly opportunities, such as elective rotations and fellowship training, are explored.     

Systems-Based Practice: The Sixth Core Competency

Systems-Based Practice (SBP) is the sixth competency defined by the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. Specifically, SBP requires "Residents [to] demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value." This competency can be divided into four subcompetencies, all of which are integral to training emergency medicine (EM) physicians: resources, providers, and systems; cost-appropriate care; delivery systems; and patient advocacy. In March 2002, the Council of Emergency Medicine Residency Directors (CORD-EM) convened a consensus conference to assist residency directors in modifying the SBP competency specific for EM. The Consensus Group modified the broad ACGME definition for SBP into EM-specific goals and objectives for residency training in SBP. The primary assessment methods from the Toolbox of Assessment Methods were also identified for SBP. They are direct observation, global ratings, 360-degree evaluations, portfolio assessment, and testing by both oral and written exams. The physician tasks from the Model of the Clinical Practice of Emergency Medicine that are most relevant to SBP are out-of-hospital care, modifying factors, legal/professional issues, diagnostic studies, consultation and disposition, prevention and education, multitasking, and team management. Suggested EM residency curriculum components for SBP are already in place in most residency programs, so no additional resources would be required for their implementation. These include: emergency medical services and administrative rotations, directed reading, various interdisciplinary and hospital committee participation, continuous quality improvement project participation, evidence-based medicine instruction, and various didactic experiences, including follow-up, interdisciplinary, and case conferences. With appropriate integration and evaluation of this competency into training programs, it is likely that future generations of physicians and patients will reap the benefits of an educational system that is based on well-defined outcomes and a more systemic view of health care.     

Off‐service Resident Education in the Emergency Department: Outline of a National Standardized Curriculum

Although many residency programs mandate at least one rotation in emergency medicine (EM), to the best of our knowledge, a standardized curriculum for emergency department (ED) rotations for “off‐service” residents has not been developed. As a result, the experiences of these residents in the ED tend to vary during their rotations. To design an off‐service EM curriculum, we adopted Kern’s six‐step approach to curriculum development as a conceptual framework. The resulting program encompasses clinical experience and didactic sessions through which residents are trained in core topics and skills. This knowledge will be applicable in the clinical settings in which residents will continue to train and ultimately practice their specialty. It is flexible enough to be applicable and implementable without being limited by resource availability or faculty strengths.     

Promoting Diversity in Emergency Medicine: Summary Recommendations from the 2008 Council of Emergency Medicine Residency Directors (CORD) Academic Assembly Diversity Workgroup

Although the U.S. population continues to become more diverse, ethnic and racial health care disparities persist. The benefits of a diverse medical workforce have been well described, but the percentage of emergency medicine (EM) residents from underrepresented groups (URGs) is small and has not significantly increased over the past 10 years. The Council of Emergency Medicine Resident Directors (CORD) requested that a panel of CORD members review the current state of ethnic and racial diversity in EM training programs. The objective of the discussion was to develop strategies to help EM residency programs examine and improve diversity in their respective institutions. Specific recommendations focus on URG applicant selection and recruitment strategies, cultural competence curriculum development, involvement of URG faculty, and the availability of institutional and national resources to improve and maintain diversity in EM training programs.     

The Development of a National Emergency Medical Services Curriculum Framework for Physicians in Canada

Background. As the role of emergency medical services (EMS) continues to expand, EMS physicians andmedical directors require special skills andtraining to keep pace with the rapidly evolving subspecialty of EMS. In Canada, subspecialty training in EMS is still relatively new, anda standard national curriculum for physician EMS training does not exist. Objective. To develop a national EMS curriculum for emergency medicine (EM) residents andfellows andan abbreviated curriculum for non-EM trainees andcommunity physicians. Methods. The authors obtained EMS curricula andopportunities from Canadian EM andEMS training programs anda sample of U.S. programs to determine existing curricula, anddeveloped a framework for a national EMS curriculum using an expert working group of EMS medical directors andEMS leaders in Canada. Results. Canadian EM residency training programs included an EMS rotation, but their content anddepth of training were not uniform. The expert working group proposed a comprehensive set of training objectives, grouped into 16 categories, stratified by level of training. Conclusion. The proposed framework andobjectives are suitable for training medical students, family medicine trainees, community physicians, EM residents, andEMS fellows in Canada. The authors hope this article will serve as a guideline for residency andfellowship directors to develop their EMS training programs in a consistent manner, promote formal training for physicians involved in EMS, andhelp define the specific knowledge andexpertise required of physicians who provide EMS medical direction in Canada.     

Effect of Changes in Graduate Medical Education Funding on Emergency Medicine Residency Programs

OBJECTIVE: To determine whether changes in graduate medical education (GME) funding have had an impact on emergency medicine (EM) residency training programs. METHODS: A 34-question survey was mailed to the program directors (PDs) of all 115 Accreditation Council for Graduate Medical Education (ACGME)-accredited EM residency programs in the United States in the fall of 1998, requesting information concerning the impact of changes in GME funding on various aspects of the EM training. The results were then compared with a similar unpublished survey conducted in the fall of 1996. RESULTS: One hundred one completed surveys were returned (88% response rate). Seventy-one (70%) of the responding EM residency programs were PGY-I through PGY-III, compared with 55 (61%) of the responding programs in 1996. The number of PGY-II through PGY-IV programs decreased from 25 (28%) of responding programs in 1996 to 17 (16%). The number of PGY-I through PGY-IV programs increased slightly (13 vs 10); the number of EM residency positions remained relatively stable. Fifteen programs projected an increase in their number of training positions in the next two years, while only three predicted a decrease. Of the respondents, 56 programs reported reductions in non-EM residency positions and 35 programs reported elimination of fellowship positions at their institutions. Only four of these were EM fellowships. Forty-six respondents reported a reduction in the number of non-EM residents rotating through their EDs, and of these, 11 programs reported this had a moderate to significant effect on their ability to adequately staff the ED with resident physicians. Sixteen programs limited resident recruitment to only those eligible for the full three years of GME funding. Eighty-seven EM programs reported no change in faculty size due to funding issues. Sixty-two programs reported no change in the total number of hours of faculty coverage in the ED, while 34 programs reported an increase. Three EM programs reported recommendations being made to close their residency programs in the near future. CONCLUSIONS: Changes in GME funding have not caused a decrease in the number of existing EM residency and fellowship training positions, but may have had an impact in other areas, including: an increase in the number of EM programs structured in a PGY-I through PGY-III format (with a corresponding decrease in the number of PGY-II through PGY-IV programs); a decrease in the number of non-EM residents rotating through the ED; restriction of resident applicants who are ineligible for full GME funding from consideration by some EM training programs; and an increase in the total number of faculty clinical hours without an increase in faculty size.     

The Search for Common Ground: Developing Emergency Medicine in Iran

Academic ties between Iran and the United States were extensive before the 1979 revolution in Iran. After 20 years of negligible academic exchanges, there has been a growing trend of professional contacts between the two countries over the past few years. The genuine warmth of friendship and commitment to excellence in emergency medicine (EM) among Iranians has transcended the political barriers to allow international contribution of EM development in the country. Since 1999, there has been a successful academic collaboration between Iranian and U.S. universities to help develop EM in Iran. Today, remarkable progresses have been achieved through recognition of EM as a distinct profession, developing EM residency programs, improving emergency medical services, establishing qualified emergency departments, training faculty and staff, starting physician exchange programs, and building mutual contributions with professionals throughout the world. A supportive policy environment and a high-quality health care system have had incredible impacts on EM development in the country.     

2001-2002 SAEM Emergency Medicine Faculty Salary and Benefits Survey

OBJECTIVE: The Society for Academic Emergency Medicine (SAEM) commissioned an emergency medicine (EM) faculty salary and benefits survey for all 2001 residency review committee (RRC)-EM-accredited programs using the SAEM fifth-generation survey instrument. Responses were collected by SAEM and blinded from the investigators. Data represent compensation paid for the 2001-02 academic year. Seventy-six of 124 (61%) accredited programs responded, yielding usable data on 1,355 full-time faculty representing all four Association of American Medical Colleges (AAMC) regions. METHODS: Blinded program and individual faculty data were entered into a customized version of Filemaker Pro, a relational database program with a built-in statistical package. Salary data were sorted by criteria such as program region, faculty title, American Board of Emergency Medicine (ABEM) certification, academic rank, years postresidency, program size, and whether data were reported to the AAMC. Demographic data were analyzed with regard to numerous criteria, including department staffing levels, emergency department (ED) volumes, ED length of stay, department income sources, salary incentive components, research funding, and specific type and value of fringe benefits offered. Data were compared with those from previous SAEM studies. RESULTS: Mean salaries were reported as follows: all faculty, $180,913; first-year faculty, $147,746; programs reporting data to the AAMC, $174,354; programs not reporting data to the AAMC, $191,397. Mean salaries as reported by AAMC region: northeast, $178,593; south, $176,314; midwest, $200,095; west, $166,779. Full-time emergency medicine residency program faculty work an average of 1,129 clinical hours per year. CONCLUSIONS: Reported salaries for full-time EM residency faculty have risen approximately 8.7% since the last survey. Up to approximately 1,200 clinical hours worked per year, salary varies inversely with clinical hours worked. Total per-faculty patient contact time (overall workload) has grown approximately 13% since the last survey. Patient wait times have increased approximately 27% since the last survey. Significant regional differences in salaries have been present in all five SAEM surveys. Emergency medicine residency faculty continue to work at the upper extremes of patient encounters per physician, patient acuity levels, and department lengths of stay.     

Emergency Medicine Residency Training in Electrocardiogram Interpretation

OBJECTIVES: A national survey of emergency medicine (EM) residency program directors (PDs) was conducted to review training and evaluation of residents in electrocardiogram (ECG) interpretation and to assess the attitudes of PDs toward establishing national criteria for ECG competency. METHODS: An eight-question multiple-part survey was mailed to all 122 EM PDs. The presence of a formal ECG curriculum, teaching formats, and methods to assess competency were queried. The PDs' opinions on developing a national ECG curriculum, standardized assessment tool, and competency requirement for graduation were solicited on a five-point Likert scale. RESULTS: Surveys were received from 87 (71.3%) of the 122 EM residency programs. Of the responding programs, 56 (64.4%) had a formal ECG curriculum. Only 18 (20.7%) programs stated that they test for ECG competency, and even fewer, ten (11.5%) programs, require that residents prove competency to graduate. Although 32 (48.3%) PDs endorsed the idea of a national ECG curriculum, 51 (58.6%) opposed the implementation of a national ECG examination for EM. Similarly, 50 (57.5%) PDs opposed a national ECG competency requirement for graduation. CONCLUSIONS: While a majority of EM residency programs surveyed have a formal curriculum for ECG interpretation, less than a fourth formally test their residents or require proof of competency. The majority of residency PDs oppose the development of a national ECG examination or competency requirement for graduation. Implementation of the Accreditation Council for Graduate Medical Education directive for the demonstration of clinical competencies will be challenging given the current position of PDs.     

Pediatric Emergency Medicine Education in Emergency Medicine Training Programs

BACKGROUND: The educational goal of emergency medicine (EM) programs has been to prepare its graduates to provide care for a diverse range of patients and presentations, including pediatric patients. OBJECTIVE: To evaluate the methods used to teach pediatric emergency medicine (PEM) to EM residents. METHODS: A written questionnaire was distributed to 118 EM programs. Demographic data were requested concerning the type of residency program, number of residents, required pediatric rotations, elective pediatric rotations, type of hospital and settings in which pediatric patients are seen, and procedures performed. Information was also requested on the educational methods used, proctoring EM received, and any formal curriculum used. RESULTS: Ninety-four percent (111/118) of the programs responded, with 80% of surveys completed by the residency director. Proctoring was primarily performed by PEM attendings and general EM attendings. Formal means of PEM education most often included the EM core curriculum (94%), journal club (95%), EM grand rounds (94%), and EM morbidity and mortality (M&M) conference (91%). Rotations and electives most often included the pediatric intensive care unit (PICU) and the emergency department (ED) (general and pediatric). CONCLUSIONS: Emergency medicine residents are exposed to PEM primarily by rotating through a general ED, the PED, and the PICU, being proctored by PEM and EM attendings and attending EM lectures and EM M&M conferences. Areas that may merit further attention for pediatric emergency training include experience in areas of neonatal resuscitation, pediatric M&M, and specific pediatric electives. This survey highlights the need to describe current educational strategies as a first step to assess perceived effectiveness.     

Teaching Patient Empathy The ED Visit Program

OBJECTIVE: Residency programs only are not challenged with developing competent emergency clinicians, but should strive to develop caring, empathetic, and community-minded physicians. An exercise was designed to help residents experience emergency department (ED) visits from the patient's perspective. METHODS: This study occurred in emergency medicine residency program at an urban teaching institution with an annual ED census of 94,000. On the first day of residency orientation, each resident was given a clinical scenario and registered through triage into the ED. Nurses were blinded to the study. The study concluded when the examining physician entered the exam room. Residents were then presented with a simulated bill based on their scenario. Residents completed a survey initially and at six months. Survey ratings were measured using a 100-mm visual analog scale (VAS) (0 = not at all; 100 = a great deal). RESULTS: Twenty-five residents participated over two years. Sixty-four percent had never been an ED patient before. Median length of stay was 139 minutes. This exercise was found to improve resident empathy for patients on initial survey, 66 mm (range 16-71), and at follow-up, 66 mm (range 23-91). Residents found the exercise useful both initially, 50 mm (range 4-86), and at follow-up, 49 mm (range 15-81). Ninety-two percent of the residents thought the goals of the exercise had been met. Residents also stated the study changed their approach to patient care (45 mm, range 4-76) and made them a better physician (49 mm, range 5-80). CONCLUSIONS: The ED visit study enhanced patient empathy within residents and was useful in improving patient care attitude.     

A survey to determine the prevalence and characteristics of training in Evidence-Based Medicine in emergency medicine residency programs

We conducted a survey to determine the prevalence, training methods, and allotment of time for teaching evidence-based medicine (EBM) skills within accredited Emergency Medicine (EM) residency programs in the United States. A survey was mailed to program directors of all 122 accredited Emergency Medicine residency programs. The survey was also sent to program directors using an e-mail listserv. Responses were obtained from 53% of programs; 80% (95% CI: 68-89) of EM programs reported teaching some EBM. Although respondents believed a median of 10 hours were required to adequately cover this topic, only 22% provided more than 5 hours per year. Sixtey-three percent (95% CI: 50-75) of respondents reported using the JAMA Users' Guides series in journal club and 83% reported efforts to link journal clubs to patient care. Perceived barriers to integrating EBM into teaching and patient care included lack of trained faculty, lack of time, lack of familiarity with EBM resources, insufficient funding, and lack of interested faculty. In summary, academic EM programs are attempting to train residents in EBM, but perceive a lack of trained faculty, time, and funding as barriers. Desired resources include a defined curriculum, on-line training for faculty, and defined strategies for integration of EBM into training and patient care.     

Executive Summary: The Institute of Medicine Report and the Future of Academic Emergency Medicine: The Society for Academic Emergency Medicine and Association of Academic Chairs in Emergency Medicine Panel: Association of American Medical Colleges Annual Meeting, October 28, 2006

The findings in the Institute of Medicine's Future of Emergency Care reports, released in June 2006, emphasize that emergency physicians work in a fragmented system of emergency care with limited interhospital and out‐of‐hospital care coordination, too few on‐call specialists, minimal disaster readiness, strained inpatient resources, and inadequate pediatric emergency services. Areas warranting special attention at academic medical centers (AMCs), both those included within the report and others warranting further attention, were reviewed by a distinguished panel and include the following: 1) opportunities to strengthen and leverage the educational environment within the AMC emergency department; 2) research opportunities created by emergency medicine (EM) serving as an interdisciplinary bridge in the area of clinical and translational research; 3) enhancement of federal guidelines for observational and interventional emergency care research; 4) recognition of the importance of EM residency training, the role of academic departments of EM, and EM subspecialty development in critical care medicine and out‐of‐hospital and disaster medicine; 5) further assessment of the impact of a regional emergency care model on patient outcomes and exploration of the role of AMCs in the development of such a model (e.g., geriatric and pediatric centers of EM excellence); 6) the opportunity to use educational loan forgiveness to encourage rural EM practice and the development of innovative EM educational programs linked to rural hospitals; and 7) the need to address AMC emergency department crowding and its adverse effect on quality of care and patient safety. Strategic plans should be developed on a local level in conjunction with support from national EM organizations, allied health care, specialty organizations, and consumer groups to help implement the recommendations of the Institute of Medicine report. The report recommendations and other related recommendations brought forward during the panel discussions should be addressed through innovative programs and policy development at the regional and federal levels.