19 A Novel Approach to Residency Education in EMS: The MD-PM Ambulance

Challenge:  Indiana University EM residents have actively provided prehospital care as crew members on a hospital-based air ambulance service. This service functions as a secondary responder for high acuity patients who have already had first tier evaluation and care. First response, ground EMS experiences have been observational only as residents have ridden along with a two-paramedic team on an urban ambulance service for 24 hours during their residency careers. Resident understanding of first response care and challenges faced by initial EMS providers has been limited to that gleaned during their observational period.
Solution:  Most EM residencies do not provide opportunities for residents to function as first response providers. Therefore, we developed a Physician-Paramedic team to provide first response care within a busy metropolitan area. This two-member team operates within a "geozone" that includes a diverse patient population with both medical and trauma complaints. Unlike other residency ground EMS programs, the MD-PM truck responds primarily to all ambulance requests within their designated geozone and assists outside their designated geozone for multi-patient casualties in which a physician response would benefit patient care (fires, motor vehicle accidents, multiple gunshot victims). Residents on the MD-PM truck not only provide care equivalent to that expected of a nationally certified paramedic (IVs, drug administration, splinting, packaging), but also perform advanced skills such as RSI which is outside the scope of a traditional two-paramedic team. Immersion into the first response ground EMS system will provide valuable insight into the challenges of providing care outside of the hospital.     

13 Knowledge Translation Shift

Health care providers have demonstrated difficulty in adopting the latest information into their clinical practice patterns. This gap in "Knowledge Translation" (KT) is currently under broad discussion within the medical community and was the focus of SAEM's Consensus Conference in 2007. In an effort to bridge this gap, we implemented a novel "KT shift" for our PGY-2 residents. PGY-2 emergency medicine (EM) residents are required to work a nine hour KT shift during their scheduled EM rotation at one of two large urban training emergency departments (EDs). This shift has reduced patient responsibilities to allow for the development of clinical queries that are answered by searching for the best evidence to be applied to patient care. This process is summarized on a "KT Shift Log" that records the PICO question, databases searched, and level of evidence found to answer clinical questions. KT shift log sheets and search strategies are reviewed by EM faculty with expertise in evidence-based medicine and KT principles. We believe that the implementation of a KT shift will improve residents' ability to obtain high quality evidence to answer real-time clinical questions. This may serve as an important measure in closing the knowledge to practice gap.     

Graduate Medical Education and Knowledge Translation: Role Models, Information Pipelines, and Practice Change Thresholds

This article reflects the proceedings of a workshop session, Postgraduate Education and Knowledge Translation, at the 2007 Academic Emergency Medicine Consensus Conference on knowledge translation (KT) in emergency medicine (EM). The objective was to develop a research strategy that incorporates KT into EM graduate medical education (GME). To bridge the gap between the best evidence and optimal patient care, Pathman et al. suggested a multistage model for moving from evidence to action. Using this theoretical knowledge‐to‐action framework, the KT consensus conference group focused on four key components: acceptance, application, ability, and remembering to act on the existing evidence. The possibility that basic familiarity, along with the pipeline by Pathman et al., may improve KT uptake may be an initial starting point for research on GME and KT. Current residents are limited by faculty GME role models to demonstrate bedside KT principles. The rapid uptake of KT theory will depend on developing KT champions locally and internationally for resident physicians to emulate. The consensus participants combined published evidence with expert opinion to outline recommendations for identifying the barriers to KT by asking four specific questions: 1) What are the barriers that influence a resident's ability to act on valid health care evidence? 2) How do we break down these barriers? 3) How do we incorporate this into residency training? 4) How do we monitor the longevity of this intervention? Research in the fields of GME and KT is currently limited. GME educators assume that if we teach residents, they will learn and apply what they have been taught. This is a bold assumption with very little supporting evidence. This article is not an attempt to provide a complete overview of KT and GME, but, instead, aims to create a starting point for future work and discussions in the realm of KT and GM.     

7 Layered Simulation: A Novel Approach to Medical Malpractice Education

Overview:  We present a novel approach to the use of simulation in medical education with a two-event layered simulation. A patient care simulation with an adverse outcome was followed by a delayed simulated deposition.
Process:  Senior residents in an academic emergency medicine program were solicited as simulation research volunteers. Other than stating that the research involved adverse outcomes, no identifying information was given. Seven volunteers participated in a simulation involving a forced error (nurse confederate gave an incorrect medication dose). Based on the initial simulation, one physician completed a simulated deposition in a teaching conference six weeks later conducted by a licensed attorney with malpractice experience. The audience, consisting of residents, attendings, and students, watched a recording of the patient care, witnessed the deposition, and evaluated the experience using a 13 question survey with five-point Likert scales.
Outcome:  Participants felt that, overall, the training program was a useful educational tool (average Likert score of 4.63) that would change aspects of their practice (3.31). Participants stated that they would be more careful in their documentation (3.88), review high risk situations with staff (4.00), and monitor more carefully for errors (3.95). Overall, there was a degree of increased fear of the litigation process (3.95), but participants felt they would improve the risk profile of their practices (3.70).
Conclusion:  A novel approach to medical education was successful in changing attitudes and provided an expanded educational experience for participants. Layered simulation can be successfully incorporated into educational programs for numerous issues including medical malpractice.     

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.     

Point‐of‐Care Ultrasound in General Surgery Residency Training: A Proposal for Milestones in Graduate Medical Education Ultrasound

The use of point‐of‐care ultrasound (US) in the clinical setting has undergone massive growth, although its incorporation into training and practice is variable. Surgeons are interested in using point‐of‐care US and can incorporate it effectively into clinical practice. However, the current state of point‐of‐care US training in general surgery is inadequate. The Accreditation Council for Graduate Medical Education introduced the Milestones Project to evaluate resident and fellow performance. Emergency medicine is the only specialty with a point‐of‐care US milestone. We have successfully implemented a US training program into our general surgery residency curriculum and now propose milestones in point‐of‐care US for all general surgery residents.     

16 A Novel Approach to "See One, Do One": Multimedia Presentations before Procedure Workshops and Simulation

We propose that residents and medical students are likely to gain more from a simulation experience or procedure workshop if they are given educational materials conveying key concepts to review beforehand. Several multimedia formats are available to accomplish this task. Digital video and Powerpoint presentations can be converted to podcasts with or without audio tracks using programs like Profcast, GarageBand, Camtasia, and Keynote. There are also procedure videos available from sources like the New England Journal of Medicine. Participants are provided these instructional materials via a secure web server or email attachment several days prior to the educational session. These presentations are kept short in length (no greater than 10-15 minutes) to optimize compliance while delivering information efficiently. They can be reviewed at the learner's convenience on a personal computer or on an iPod with video capability. This method can significantly reduce the time required for didactic teaching in a procedure workshop; for example, when medical students review a video on basic suturing before attending a suturing workshop, they are prepared to begin practicing with minimal initial instruction. Furthermore, conveying the same information repeatedly through different instructional methods can help learners consolidate knowledge, as in the case of a presentation provided to residents before a simulation session containing the basic clinical teaching points of the case. Participant feedback regarding these resources has been favorable.     

Knowledge Translation in International Emergency Medical Care

More than 90% of the world population receives emergency medical care from different types of practitioners with little or no specific training in the field and with variable guidance and oversight. Emergency medical care is being recognized by actively practicing physicians around the world as an increasingly important domain in the overall health services package for a community. The know-do gap is well recognized as a major impediment to high-quality health care in much of the world. Knowledge translation principles for application in this highly varied young domain will require investigation of numerous aspects of the knowledge synthesis, exchange, and application domains in order to bring the greatest benefit of both explicit and tacit knowledge to increasing numbers of the world's population. This article reviews some of the issues particular to knowledge development and transfer in the international domain. The authors present a set of research proposals developed from a several-month online discussion among practitioners and teachers of emergency medical care in 16 countries from around the globe and from all economic strata, aimed at improving the flow of knowledge from developers and repositories of knowledge to the front lines of clinical care.     

An Evaluation of Pediatric Residency Education in Conveying Immunization Knowledge

Background: The Accreditation Council of Graduate Medical Education now requires all pediatric residency training programs assess medical knowledge competency. Purpose: The goal of this project was to determine whether pediatric residency training using patient-based/experiential teaching made residents competent in the area of immunization knowledge or whether additional teaching strategies might need to be developed. Methods: Cross-sectional and longitudinal study designs were used to determine improvement in immunization knowledge on a multiple-choice quiz over the 3 years of residency training. Results: Both the cross-sectional and longitudinal data showed a statistically significant improvement in performance between residency training Years 1 and 2 but not between Years 2 and 3 on the quiz. This statistically significant relationship by year of training was seen despite the modest reliability of the short quiz and the sample size. Conclusions: This study shows that pediatric residency education using patient-based/experiential teaching is effective in teaching first year residents about immunization knowledge but is not as effective for 2nd- and 3rd-year residents. Other instructional methods such as computer-based cases could be employed during the 2nd and 3rd years.     

Report from the Council of Emergency Medicine Residency Directors Subcommittee on Graduate Medical Education Funding: Effects of Decreased Medicare Support

INTRODUCTION: Recent changes by the Health Care Financing Administration (HCFA) have resulted in decreased Medicare support for emergency medicine (EM) residencies. OBJECTIVE: To determine the effects of reduced graduate medical education (GME) funding support on residency size, resident rotations, and support for a fourth postgraduate year (PGY) of training and for residents with previous training. METHODS: A 36-question survey was developed by the Council of Emergency Medicine Residency Directors (CORD) committee on GME funding and sent to all 122 EM program directors (PDs). Responses were collected by the Society for Academic Emergency Medicine (SAEM) office and blinded with respect to the institution. RESULTS: Of 122 programs, 109 (89%) responded, of which 78 were PGY 1-3 programs, 19 were PGY 2-4, and 12 were PGY 1-4. The PDs were asked specifically whether there were changes in program size due to changes in Medicare reimbursement. Although few programs (12%) decreased their size or planned to decrease their size, 39% had discussions regarding decreasing their size. Thirty percent of the PDs responded that other programs at their institution had already decreased their size; 26% of the PDs had problems with financing outside rotations; and 24% had a decrease in off-service residents in their emergency departments (EDs). Only seven (6%) of programs paid residents from practice plan dollars, while most (82%) were fully supported by federal GME funding. Nearly all four-year programs (97%) received full resident salary support from their institutions and 77% of programs accept residents with previous training. CONCLUSIONS: Nearly all EM programs are fully supported by their institutions, including the fourth postgraduate year. Most programs take residents with previous training. Although few programs have reduced their size, many are discussing this. Many programs have had difficulty with funding off-service rotations and many have had decreased numbers of off-service residents in their EDs. Recent GME funding changes have had adverse effects on EM residency programs.     

Emergency Medical Services Education in Emergency Medicine Residency Programs: A National Survey

Objectives: Emergency medical services (EMS) was recently approved as a subspecialty by the American Board of Medical Specialties, highlighting the core content of knowledge that encompasses prehospital emergency patient care. This study aimed to describe the current state of EMS education at emergency medicine (EM) residency programs in the United States. Methods: The authors distributed an online survey containing multiple‐choice and free‐response questions pertaining to resident EMS education to the directors of EM residency programs in the United States between July 21 and September 10, 2010. Results: Of 154 programs, 117 (75%) responded to the survey, and 108 (70%) completed the survey by answering all required questions. Of completed surveys, 82 programs (76%) reported the cumulative time devoted to EMS didactic education during the course of residency training, a median of 20 hours (range = 3 to 300 hours; interquartile range [IQR] = 12 to 36 hours). There is a designated EMS rotation in 89% of programs, with a median duration of 3 weeks (range = 1 to 9 weeks; IQR = 2 to 4 weeks). Most programs involve residents on EMS rotations strictly as in‐field observers (63%), some as in‐field providers (20%), and the rest with some combination of the two roles. Ground ride‐along is required in 94% of programs, while air ride‐along is mandatory in 4% and optional in 81% of programs. Direct medical oversight (DMO) certification is required in 41% of residency programs, but not available in 26% of program jurisdictions. Residents in 92% of programs provide DMO. In those programs, most residents (77%) provide DMO primarily while working in the emergency department (ED), 13% during dedicated EMS or medical oversight shifts, and 4% during a combination of these shifts. Disaster‐preparedness was most frequently listed as the component programs would like to add to their EMS curricula. Conclusions: There is a wide range in the didactic, online, and in‐field EMS educational experiences provided as part of EM training. Most residents participate in ground ride‐along activities, provide DMO, and have a dedicated EMS rotation. Disaster‐preparedness is the most common desired addition to existing EMS rotations. ACADEMIC EMERGENCY MEDICINE 2012; 19:1–6 © 2012 by the Society for Academic Emergency Medicine     

See One, Do One, Teach One: Advanced Technology in Medical Education

The concept of "learning by doing" has become less acceptable, particularly when invasive procedures and high-risk care are required. Restrictions on medical educators have prompted them to seek alternative methods to teach medical knowledge and gain procedural experience. Fortunately, the last decade has seen an explosion of the number of tools available to enhance medical education: web-based education, virtual reality, and high fidelity patient simulation. This paper presents some of the consensus statements in regard to these tools agreed upon by members of the Educational Technology Section of the 2004 AEM Consensus Conference for Informatics and Technology in Emergency Department Health Care, held in Orlando, Florida. Findings: Web-based teaching: 1) Every ED should have access to medical educational materials via the Internet, computer-based training, and other effective education methods for point-of-service information, continuing medical education, and training. 2) Real-time automated tools should be integrated into Emergency Department Information Systems [EDIS] for contemporaneous education. Virtual reality [VR]: 1) Emergency physicians and emergency medicine societies should become more involved in VR development and assessment. 2) Nationally accepted protocols for the proper assessment of VR applications should be adopted and large multi-center groups should be formed to perform these studies. High-fidelity simulation: Emergency medicine residency programs should consider the use of high-fidelity patient simulators to enhance the teaching and evaluation of core competencies among trainees. CONCLUSIONS: Across specialties, patient simulation, virtual reality, and the Web will soon enable medical students and residents to... see one, simulate many, do one competently, and teach everyone.     

4 A Multimedia Web-based Interactive Quiz Module for the Education of Emergency Medical Personnel

A dynamic database-driven website was introduced in 2002. This site has served successfully as a learning tool with its annual update and addition of interactive case and quiz modules. To extend web-based learning as an educational tool, we developed a multimedia web-based module for emergency medicine, with video and audio enhancements to simulate patient encounters in the emergency ward setting. Central to the web-module development is the creation of a relational database. We use FileMaker Pro with search, storage, retrieval, image, video and audio incorporation functions, and a built-in interface that allows display of database contents in web templates. Initially the patient's history and presentation are presented with a 30–60 second video followed by key physical findings. The diagnostic studies and management of the patient are then available through sequential interactive quizzes and feedback replies, presented in audio-, video- and image-oriented formats. The format of the quizzes themselves simulates medical board questions. Initial feedback has been favorable. The majority of emergency medicine personnel feel that this module complements and enhances regular lecture sessions. In addition, it enables preservation of interesting and/or infrequently encountered cases for viewing by all residents in Emergency Medicine.     

Nurse Managed Clinics: an Approach to Graduate Community Health Nursing Education

In summary, nurse managed clinics can be another step toward narrowing the gap between education and service and providing a non-traditional setting for the developing of leaders in futuristic nursing.     

The Canadian Prehospital Evidence-based Protocols Project: Knowledge Translation in Emergency Medical Services Care

Objectives:  The principles of evidence-based medicine are applicable to all areas and professionals in health care. The care provided by paramedics in the prehospital setting is no exception. The Prehospital Evidence-based Protocols Project Online (PEP) is a repository of appraised research evidence that is applicable to interventions performed in the prehospital setting and is openly available online. This article describes the history, current status, and potential future of the project.
Methods:  The primary objective of the PEP is to catalog and grade emergency medical services (EMS) studies with a level of evidence (LOE). Subsequently, each prehospital intervention is assigned a class of recommendation (COR) based on all the appraised articles on that intervention, in an effort to organize the evidence so it may be put into practice efficiently. An LOE is assigned to each article by the section editor, based on the study rigor and applicability to EMS. The section editor committee consists of EMS physicians and paramedics from across Canada, and two from Ireland and a paramedic coordinator. The evidence evaluation cycle is continuous; as the section editors send back appraisals, the coordinator updates the database and sends out another article for review.
Results:  The database currently has 182 individual interventions organized under 103 protocols, with 933 citations.
Conclusions:  This project directly meets recent recommendations to improve EMS by using evidence to support interventions and incorporating it into protocols. Organizing and grading the evidence allows medical directors and paramedics to incorporate research findings into their daily practice. As such, this project demonstrates how knowledge translation can be conducted in EMS.     

Systems-Based Practice in Graduate Medical Education: Systems Thinking as the Missing Foundational Construct

Background: Since 2001, residencies have struggled with teaching and assessing systems-based practice (SBP). One major obstacle may be that the competency alone is not sufficient to support assessment. We believe the foundational construct underlying SBP is systems thinking, absent from the current Accreditation Council for Graduate Medical Education competency language. Summary: Systems thinking is defined as the ability to analyze systems as a whole. The purpose of this article is to describe psychometric issues that constrain assessment of SBP and elucidate the role of systems thinking in teaching and assessing SBP. Conclusion: Residency programs should incorporate systems thinking models into their curricula. Trainees should be taught to understand systems at an abstract level, in order to analyze their own healthcare systems, and participate in quality and patient safety activities. We suggest that a developmental trajectory for systems thinking be developed, similar to the model described by Dreyfus and Dreyfus.     

Problems No One Looked For: Philosophical Expeditions into Medical Education

Abstract

Issue: Medical education has “muddy zones of practice,” areas of complexity and uncertainty that frustrate the achievement of our intended educational outcomes. Slowing down to consider context and reflect on practice are now seen as essential to medical education as we are called upon to examine carefully what we are doing to care for learners and improve their performance, professionalism, and well-being. Philosophy can be seen as the fundamental approach to pausing at times of complexity and uncertainty to ask basic questions about seemingly obvious practices so that we can see (and do) things in new ways. Evidence: Philosophy and medical education have long been related; many of our basic concepts can be traced to philosophical ideas. Philosophy is a problem-creation approach, and its method is analysis; it is a constant process of shifting frames and turning into objects of analysis the lenses through which we see the world. However, philosophy is not about constant questioning for the sake of questioning. Progression in medical education practice involves recognizing when to switch from a philosophical to a practical perspective, and when to switch back. Implications: In medical education, a philosophical approach empowers us to “slow down when we should,” thereby engaging us more directly with our subjects of study, revealing our assumptions, and helping us address vexing problems from a new angle. Doing philosophy involves thinking like a beginner, getting back to basics, and disrupting frames of reference. Being philosophical is about wonder and intense, childlike curiosity, human qualities we all share. Taking a philosophical approach to medical education need not be an unguided endeavor, but can be a dialog through which medical educators and philosophers learn together.     

Knowledge Translation in the Emergency Medical Services: A Research Agenda for Advancing Prehospital Care

Little is known about knowledge translation in the practice of out-of-hospital medicine. It is generally accepted that much work is needed regarding "getting the evidence straight" in emergency medical services, given the substantial number of interventions that are performed regularly in the field but lack meaningful scientific support. Additional attention also needs to be given to "getting the evidence used," because there is some evidence that evidence-based practices are being incompletely or incorrectly applied in the field. In an effort to help advance a research agenda for knowledge translation in emergency medical services, nine recommendations are put forth to help address the problems identified.