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.     

Clerkships in Emergency Medicine

Planning for clerkships in emergency medicine (EM) can be stressful, prolonged, and challenging. Therefore, medical students should start planning for them early. In this article, we offer guidance regarding several issues pertinent to the EM clerkship, such as the best time to schedule one (or more) during medical school, the most appropriate institution or program to schedule it, the process of selecting and applying for the clerkship, and the number of EM clerkships to consider. We will explain why an EM clerkship should be scheduled between June and October and the reason that 2 EM clerkships at different sites are sufficient for the majority of students. Additionally, we emphasize that clerkships in emergency departments associated with EM residency programs or with reputations for outstanding student teaching tend to be most beneficial. Above all, students interested in EM should attempt to leave a great impression after completing their clerkships by providing stellar patient care, demonstrating enthusiasm at all times, and maintaining professionalism. In turn, they will gain knowledge and clinical experiences that should prove valuable in their future.     

Prospective Evaluation of Emergency Medicine Instruction for Rotating First–postgraduate–year Residents

Objective: To determine whether either bedside teaching alone (group A) or bedside teaching with written course materials (group B) improved written examination scores, satisfaction with the rotation, or clinical grades of rotating PGY1 residents.
Methods: A prospective, controlled educational trial was conducted. Sixty–five PGY1 residents from diverse specialties rotated in the ED for one month over a ten–month study period, and were included in the study. The PGY1 residents were assigned to group by month of rotation. All the PGY1 residents received unstructured bedside teaching by emergency medicine (EM) residents and faculty. In addition, group B received written course materials on day 1.
Results: Mean posttest scores were higher than mean pretest scores for the interns considered as a whole (p < 0.0001), but mean pretest, posttest, and clinical grades were comparable across instructional groups. Mean satisfaction ratings were higher for group A than for group B (p < 0.015). The interns specializing in EM achieved higher mean test scores (p < 0.013) and clinical grades (p < 0.003) than did the interns specializing in another medical specialty.
Conclusion: Both instructional methods were associated with improved written test performance. Written course materials did not augment bedside teaching in terms of test scores, clinical grades, or satisfaction. with the rotation. At a university–based, high–volume ED, bedside teaching offers educational benefit to rotating PGY1 residents that may not be augmented by written course materials.     

Medical Student Education in Emergency Medicine: Do Students Meet the National Standards for Clinical Encounters of Selected Core Conditions?

Background

Establishing a core curriculum for undergraduate Emergency Medicine (EM) education is crucial to development of the specialty. The Clerkship Directors in Emergency Medicine (CDEM) National Curriculum Task Force recommended that all students in a 4^th-year EM clerkship be exposed to 10 emergent clinical conditions.

Objectives

To evaluate the feasibility of encountering recommended core conditions in a clinical setting during a 4^th-year EM clerkship.

Methods

Students from three institutions participated in this ongoing, prospective observation study. Students' patient logs were collected during 4-week EM clerkships between July 2011 and June 2012. De-identified logs were reviewed and the number of patient encounters for each of the CDEM-identified emergent conditions was recorded. The percentage of students who saw each of the core complaints was calculated, as was the average number of core complaints seen by each.

Results

Data from 130 students at three institutions were captured; 15.4% of students saw all 10 conditions during their rotation, and 76.9% saw at least eight. The average number of conditions seen per student was 8.4 (range of 7.0–8.6). The percentage of students who saw each condition varied, ranging from 100% (chest pain and abdominal pain) to 31% (cardiac arrest).

Conclusions

Most students do not encounter all 10 conditions during patient encounters throughout a 4-week EM rotation, although most have exposure to at least eight. Certain conditions are far less likely than others to be encountered, and may need to be taught in a nonclinical setting.     

The Impact of the Demand for Clinical Productivity on Student Teaching in Academic Emergency Departments

OBJECTIVE: Because many emergency medicine (EM) attending physicians believe the time demands of clinical productivity limit their ability to effectively teach medical students in the emergency department (ED), the purpose of this study was to determine if there is an inverse relationship between clinical productivity and teaching evaluations. METHODS: The authors conducted a prospective, observational, double-blind study. They asked senior medical students enrolled in their EM clerkship to evaluate each EM attending physician who precepted them at three academic EDs. After each shift, students anonymously evaluated 10 characteristics of clinical teaching by their supervising attending physician. Each attending physician's clinical productivity was measured by calculating their total relative value units per hour (RVUs/hr) during the nine-month study interval. The authors compared the total RVUs/hr for each attending physician to the medians of their teaching evaluation scores at each ED using a Spearman rank correlation test. RESULTS: Seventy of 92 students returned surveys, evaluating 580 shifts taught by 53 EM attending physicians. Each attending physician received an average of 11 evaluations (median score, 5 of 6) and generated a mean of 5.68 RVUs/hr during the study period. The correlation between evaluation median scores and RVUs/hr was -0.08 (p = 0.44). CONCLUSIONS: The authors found no statistically significant relationship between clinical productivity and teaching evaluations. While many EM attending physicians perceive patient care responsibilities to be too time consuming to allow them to be good teachers, the authors found that a subset of our more productive attending physicians are also highly rated teachers. Determining what characteristics distinguish faculty who are both clinically productive and highly rated teachers should help drive objectives for faculty development programs.     

The Emergency Medicine Subinternship—A Standard Experience for Medical Students?

OBJECTIVE: To determine whether emergency medicine (EM)-bound and non-EM-bound senior medical students on the EM subinternship have a uniform experience with respect to number and acuity of patients seen and procedures performed. METHODS: Prospective observational analysis of patient diagnosis and procedures recorded in logs by students at a public teaching hospital over 12 consecutive months. Logs were reviewed blindly and assigned an acuity level based on predetermined criteria. Preselected procedures were categorized as general or surgical and tallied. Identity, specialty choice, gender, and month of rotation for each student were identified. RESULTS: Seventy of 74 students completed logs. On average, 34 EM-bound students saw 59.82 patients (95% CI = 55.19 to 64.45) and performed 10.58 procedures (95% CI = 8.62 to 12.56); 36 non-EM-bound students saw 51.17 patients (95% CI = 47.41 to 54.90) and performed 8.33 procedures (95% CI = 6.81 to 9.84). Univariate analysis showed EM-bound students saw more patients than non-EM-bound students, performed more surgical procedures, and saw higher-acuity patients (p = 0.004; 0.009; 0.016). Multivariate analyses controlled for EM specialty, gender, and month. Significant effects for EM specialty were found (ordinary least squares) for number of patients, procedures, and surgical procedures (p = 0.013; 0.048; 0.011). Logistic regression explaining acuity level showed EM specialty and gender were significant (p = 0.010; 0.038). CONCLUSIONS: In an EM subinternship, experience was variable between EM-bound and non-EM-bound students. Male students saw lower-acuity patients. The EM-bound students saw more patients, higher-acuity patients, and performed more procedures than non-EM-bound cohorts. Emergency medicine educators responsible for medical education should be aware of these differences.     

An Educator''s Guide to Teaching Emergency Medicine to Medical Students

There is a need for every medical school graduate to handle emergencies as they arise in the daily practice of medicine. Emergency medicine (EM) educators are in a unique position to provide students with basic life support skills, guidance in assessing the undifferentiated patient, and exposure to the specialty of EM during all years of medical school. Emergency physicians can become involved in a variety of education experiences that can supplement the preclinical curriculum and provide access to our specialty at an early stage. A well-designed course in the senior year allows students to develop critical thinking and patient management skills that are necessary for any medical career path. It can ensure that all medical students are exposed to the skills essential for evaluating and stabilizing the acutely ill patient. To implement this type of course, learning objectives and evaluation methods must be set when the curriculum is developed. An effective course combines didactic and clinical components that draw on the strengths of the teaching institution and faculty of the department. A structured clerkship orientation session and system for feedback to students are essential in nurturing the development of student learners. This article provides an approach to assist the medical student clerkship director in planning and implementing EM education experiences for students at all levels of training, with an emphasis on the senior-year rotation.     

Core Practical Objectives: A Means to Standardize the 4th-Year Emergency Medicine Clerkship

Background: Core Practical Objectives (CPOs) are clinical emergency medicine (EM) experiences (including suggested number of patient encounters) that students use to self-direct clerkship progress. Purpose: This study investigates feasibility of implementing EM clerkship CPOs, describes characteristics of students fulfilling CPO guidelines, and relates CPO completion to outcome measures (exam scores and grades). Methods: Cross-sectional research was conducted comparing students completing and not completing CPOs by gender, month of rotation, total patients evaluated, clerkship exam score, and final grade. Results: Over 4 years, 117 students completed an EM clerkship utilizing CPO guidelines. Gender and clerkship month were not associated with fulfilling CPOs. Total CPOs completed correlated positively with percent score on written exam and grade for rotation. Completion of specific CPOs was associated with exam scores and final grade. Conclusions: CPOs were successfully integrated into an EM clerkship. Preliminary data suggest that CPO guidelines can be used to standardize EM clerkships.     

Faculty Evaluations Correlate Poorly with Medical Student Examination Performance in a Fourth-Year Emergency Medicine Clerkship

Background

Clerkship directors routinely evaluate medical students using multiple modalities, including faculty assessment of clinical performance and written examinations. Both forms of evaluation often play a prominent role in final clerkship grade. The degree to which these modalities correlate in an emergency medicine (EM) clerkship is unclear.

Positive Outcomes of Optimizing Student–Preceptor Continuity in a Traditional Block Clerkship

Problem: Student–preceptor discontinuity during 3rd-year clerkships limits the quality and quantity of supervision, teaching, and feedback. Although longitudinal integrative clerkships increase continuity and are associated with improved student and preceptor experience, they require schoolwide curricular reform. Alternative innovations enhancing student–preceptor relationships within the constraints of a traditional block clerkship may demonstrate similar benefits. Intervention: We piloted a continuity-enhanced general pediatric ambulatory schedule during 2 consecutive clerkship blocks in 2013. Students in the continuity-enhanced model (n = 29) were assigned 1–3 primary clinic preceptors, whereas those in the traditional model (n = 30) worked with 5–8. Data were gathered from student assessments and anonymous student and preceptor surveys. We used t and Fisher's exact tests to compare the two groups and performed thematic analysis of free-text survey comments. Context: Our school utilizes a block clerkship model with approximately 30 students rotating through the pediatric clerkship every 8 weeks. During the 3-week ambulatory portion, students spend 8 half days in the general pediatric ambulatory clinic. At the conclusion of each clinic, attendings completed brief student evaluation cards. Traditionally, student and attending schedules were created independently, resulting in transient supervisory relationships and dissatisfaction with clinical engagement, feedback, and evaluation. Outcome: Seventy-three percent (43/59) of the students completed the survey. Ten general ambulatory attendings collectively completed 87.5% (35/40) of the monthly surveys. Continuity students received significantly more narrative evaluation comments (10.6 vs. 5.8, p <. 001) from general ambulatory clinic attendings and were more likely to have at least one general ambulatory clinic attending endorse being able to provide meaningful feedback and evaluation (n = 29, 100% vs. n = 20, 66.7%, p <. 001). Continuity students were also more likely to endorse being able to ask at least one of these attendings for a letter of recommendation (71.4% vs. 9.1%, p <. 001) and to have at least one general ambulatory clinic attending endorse being able to provide a meaningful letter of recommendation if asked (62.1% vs. 3.3%, p <. 001). Students (88.4%) and attendings (85.7%) preferred the continuity-enhanced schedule. The most frequent theme of both student and attending free-text survey remarks were relationships and assessment. Lessons Learned: Intentional scheduling of clerkship students to enhance preceptor continuity resulted in significant positive outcomes echoing the relationship-based educational benefits of longitudinal clerkships, particularly in regards to student assessment and feedback. Clerkship directors and other medical educators should consider implementing small changes within block clerkships to maximize student–preceptor continuity.     

Depression among Emergency Medicine Residents over an Academic Year

Objectives: To describe the frequency of depression among emergency medicine (EM) residents by month, gender, rotation type, postgraduate year (PGY), and number of hours worked.
Methods: This was a prospective, nonblinded, cohort study of consenting EM residents in a four-year, 51-resident EM residency program from July 2003 to June 2004. Participants received an anonymous monthly survey via Web site that consisted of the Center for Epidemiologic Studies Depression Scale (CESD) and the resident's gender, PGY, number of hours worked in the previous week (≤40, 41–60, 61–80 and >80), and rotation type (EM, intensive care unit, non-EM clinical, or other). Residents were excluded from analysis if they did not complete at least one survey during each season. For each resident, the peak score for each three-month period was recorded and analyzed with a mixed-model analysis of variance to account for a repeated-measures effect.
Results: Fifty of 51 (98.0%) residents consented for participation. Nineteen (38%) were excluded because of incomplete data. The prevalence of depression was 12.1% (95% confidence interval [95% CI] = 7.5% to 19.0%; 15 of 124 scores). The women had numerically, but not statistically, significantly lower mean ± standard deviation CESD scores than the men (6.4 ± 6.8 vs. 8.7 ± 8.6, p = 1.0). There was no significant difference in mean CESD score by month, PGY, rotation type, or number of hours worked.
Conclusions: Season, number of hours worked, rotation type, PGY, and gender all failed to predict depression among EM residents in this single-center trial. The prevalence of depression was comparable to that of the general population.     

Rate of Patient Workups by Non–Emergency Medicine Residents in an Academic Emergency Department

Objective: To quantify the number of patients seen per hour by non–emergency medicine (non–EM) residents in a university hospital ED.
Methods: This retrospective observational study was performed in a university hospital ED and level I trauma center. The facility had no EM residency, but was staffed with 24–hour EM faculty coverage. A computerized tracking system was searched for the number of patients seen by each of 93 non–EM residents for 12 nonconsecutive months. The ED schedule for each month was used to calculate the number of hours worked by each resident. From these figures, the number of patients seen per hour by each resident was calculated.
Results: The postgraduate years of training of the residents were as follows: 78 (84%) were PGY1, ten (11%) were PGY2, and five (5%) were PGY3. All the residents combined saw a mean 0. 95 ± 0. 20 patients/ hour, with a range from 0. 58 to 1. 75 patients/hour. There was no significant difference between the numbers of patients seen when compared by specialty using the Tukey–Kramer test (α = 0. 05).
Conclusion: The rate at which non–EM residents work up patients is consistent with previously reported rates for EM residents.     

Physical Diagnosis Skills of Physicians in Training: A Focused Assessment

Objective: To assess the proficiency of emergency medicine (EM) trainees in the recognition of physical findings pertinent to the care of the critically ill patient.
Methods: Fourteen medical students, 63 internal medicine (IM) residents, and 47 EM residents from three university-affiliated programs in Philadelphia were tested. Proficiency in physical diagnosis was assessed by a multimedia questionnaire targeting findings useful in emergencies or related to diseases frequently encountered in the ED. Attitudes toward diagnosis not based on technology, teaching practices of physical examination during EM training, and self-motivated learning of physical diagnosis also were assessed for all the EM trainees.
Results: With the exception of ophthalmology, the EM trainees were never significantly better than the senior students or the IM residents. They were less proficient than the IM residents in cardiology, and not significantly different from the IM residents in all other areas. For no organ system tested, however, did they achieve less than a 42.9% error rate (range: 42.9–72.3%, median = 54.8%). There was no significant improvement in proficiency over the three years of customary EM training. The EM residents who had received supervised teaching in physical diagnosis during training achieved a significantly higher cumulative score. The EM residents attributed great clinical importance to physical diagnosis and wished for more time devoted to its teaching.
Conclusions: These data confirm the recently reported deficiencies of physical diagnosis skills among physicians in training. The results are particularly disturbing because they relate to EM trainees and concern skills useful in the ED. Physical diagnosis should gain more attention in both medical schools and residency programs.     

Beyond the Ivory Tower: A Comparison of Grades Across Academic and Community OB/GYN Clerkship Sites

Construct: Decentralized clinical education is the use of community facilities and community physicians to educate medical students. The theory behind decentralized clinical education is that academic and community sites will provide educational equivalency as determined by objective and subjective performance measures, while training more medical students and exposing students to rural or underserved communities. One of the major challenges of decentralized clinical education is ensuring site comparability in both learning opportunities and evaluation of students. Background: Previous research has examined objective measures of student performance, but less is known about subjective performance measures, particularly in the field of obstetrics and gynecology (OB/GYN). This study explores the implications of clinical site on the adequacy of subjective and objective performance measures. Approach: This was a retrospective cohort study of 801 students in the University of Washington School of Medicine OB/GYN clerkship from 2008 to 2012. Academic sites included those with OB/GYN residency programs (n = 2) and community sites included those without residency programs (n = 29). The association between clerkship site and National Board of Medical Examiners (NBME) grade was assessed using linear regression and clinical and final grade using multinomial regression, estimating β coefficient and relative risks (RR), respectively, and 95% confidence intervals (CIs), adjusting for gender, academic quarter of clerkship, and year of clerkship. Results: There were no differences in NBME exam grades of students at academic sites (76.4 (7.3) versus 74.6 (8.0), β = –0.11, 95% CI [1.35, 1.12] compared to community sites. For clinical grade, students at community sites were 2.4 times more likely to receive honors relative to high pass (RR 2.45), 95% CI [1.72, 3.50], and for final grade, students at community sites were 1.9 times more likely to receive honors relative to pass (RR 1.98), 95% CI [1.27, 3.09], and 1.6 times more likely to receive honors relative to high pass (RR 1.62), 95% CI [1.05, 2.50], compared to those at academic sites. Conclusions: Students at community sites receive higher clinical and final grades in the OB/GYN clerkship. This highlights a significant challenge in decentralized clinical education—ensuring site comparability in clinical grading, Further work should examine the differences in sites, as well as improve standardization of clinical grading. This also underscores an important consideration, as the final grade can influence medical school rank, nomination into honor societies, and ranking of residency applicants.     

The Effect of Resident Duty-Hours Restrictions on Internal Medicine Clerkship Experiences: Surveys of Medical Students and Clerkship Directors

Phenomenon: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students’ and clerkship directors’ perceptions of the effects of the 2011 DHR on internal medicine clerkship students’ experiences with teaching, feedback and evaluation, and patient care. Approach: Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation. Findings: Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. Insights: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student–patient relationship and students’ clinical skills acquisition.     

The Impact of Two Clinical Shift Allocation Models on Student Experiences in an Emergency Medicine Clerkship

Background: Medical students on Emergency Medicine (EM) clerkships are traditionally assigned work shifts in a manner that provides a mix of daytime, evening, overnight, and weekend shifts. Whether or not this shift allocation model provides the optimal educational experience remains unclear. Purpose: The purpose of this study was to compare the impact of two different shift allocation models on the student's clerkship experience. Specifically, we set out to compare the traditional shift allocation model to a novel model designed to maximize teacher–learner continuity. Methods: This was a prospective, crossover, cohort study of medical students participating in an EM clerkship at one institution from January 1 through April 31, 2010. All students completed 2 weeks of shifts under the “traditional shift model” and 2 weeks of shifts under the “continuity-based shift model.” In the latter, the guiding principle of student shift allocation was continuity between teacher and learner. Students completed coded surveys after each 2-week block that were later matched and analyzed using 2-way ANOVAs with 1 repeated measure. In addition, all students participated in a semistructured group interview at the completion of both blocks. The interviews were recorded, transcribed, and analyzed using qualitative methods. Themes and subthemes that emerged were assessed for frequency of occurrence. Results: Eighteen medical students consented to participate. Students rated the continuity-based shift model higher on all 10 survey items. However, only the items that asked specifically about “faculty”—faculty teaching, faculty interaction, frequency and quality of faculty feedback—were rated significantly higher when students worked under the continuity-based shift model. Qualitative analysis of group interviews revealed 6 major themes and 16 subthemes. Students described feedback (N = 16/117) and the teacher–learner relationship (N = 21/117) as superior under the continuity-based shift model. Conclusions: Changes in shift allocation affects student experience in an EM clerkship. A shift allocation model that maximizes the continuity between teacher and learner is perceived by students to improve feedback and the teacher–learner relationship.     

Can Unannounced Standardized Patients Assess Professionalism and Communication Skills in the Emergency Department?

Objectives:  The authors piloted unannounced standardized patients (USPs) in an emergency medicine (EM) residency to test feasibility, acceptability, and performance assessment of professionalism and communication skills.
Methods:  Fifteen postgraduate year (PGY)-2 EM residents were scheduled to be visited by two USPs while working in the emergency department (ED). Multidisciplinary support was utilized to ensure successful USP introduction. Scores (% well done) were calculated for communication and professionalism skills using a 26-item, behaviorally anchored checklist. Residents' attitudes toward USPs and USP detection were also surveyed.
Results:  Of 27 USP encounters attempted, 17 (62%) were successfully completed. The detection rate was 44%. Eighty-three percent of residents who encountered a USP felt that the encounter did not hinder daily practice and did not make them uncomfortable (86%) or suspicious of patients (71%). Overall, residents received a mean score of 60% for communication items rated "well done" (SD ± 28%, range = 23%–100%) and 53% of professionalism items "well done" (SD ± 20%, range = 23%-85%). Residents' communication skills were weakest for patient education and counseling (mean = 43%, SD ± 31%), compared with information gathering (68%, SD ± 36% and relationship development (62%, SD ± 32%). Scores of residents who detected USPs did not differ from those who had not.
Conclusions:  Implementing USPs in the ED is feasible and acceptable to staff. The unpredictability of the ED, specifically resident schedules, accounted for most incomplete encounters. USPs may represent a new way to assess real-time resident physician performance without the need for faculty resources or the bias introduced by direct observation.