Application of the Medical Knowledge General Competency to Emergency Medicine

In February 1999, the Accreditation Council for Graduate Medical Education (ACGME) identified six general competencies as the basic educational goals required by all training programs for their residents. This places emphasis on educational outcome assessment in residency programs and in the accreditation process. A concomitant goal is to have increasingly valid, reliable assessments of the ability of a resident physician to provide safe, evidenced-based, humanistic medical care to their patients. To better define these competencies for the specialty of emergency medicine (EM), the Council of Emergency Medicine Residency Directors (CORD-EM) held a consensus conference in March 2002. This article reports the results of the Consensus Group for the core competency area of medical knowledge. This competency is already being well addressed in residency programs, but there has been inadequate documentation of a resident's knowledge base. The Consensus Group focused on many assessment methods to determine those having the best potential for use in EM programs. Assessment methods felt to be most appropriate for assessment of the medical knowledge base of a resident are presented, as are practical suggestions for incorporating these into EM programs.     

Evaluation of Student Performance: Clinical and Professional Performance

In 1999, the Accreditation Council for Graduate Medical Education (ACGME) endorsed six general competencies for residents as part of an ongoing attempt to emphasize educational outcomes as part of residency program assessment and accreditation. Although the focus of these reforms has been on postgraduate training, the competencies are applicable to medical students who aspire to become excellent clinicians and can help guide the development of assessment tools to measure clinical and professional performance of students in the emergency department. This article reviews the definitions of clinical competence and briefly addresses the issues of evaluation tool validity, reliability, and feasibility as they relate to the assessment of medical students. Several assessment tools are outlined, with an eye to the ACGME competencies and the ACGME Toolbox of Assessment Methods. The pros and cons of global rating scales, direct observation, simulations, and oral examinations are reviewed. Multiple assessment tools are often necessary to provide a true evaluation of a student's clinical and professional skills. Their application in the setting of an emergency medicine rotation is described and discussed.     

CORD‐AEUS: Consensus Document for the Emergency Ultrasound Milestone Project

In 2012, the Accreditation Council for Graduate Medical Education (ACGME) designated ultrasound (US) as one of 23 milestone competencies for emergency medicine (EM) residency graduates. With increasing scrutiny of medical educational programs and their effect on patient safety and health care delivery, it is imperative to ensure that US training and competency assessment is standardized. In 2011, a multiorganizational committee composed of representatives from the Council of Emergency Medicine Residency Directors (CORD), the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine (SAEM), the Ultrasound Section of the American College of Emergency Physicians (ACEM), and the Emergency Medicine Residents' Association was formed to suggest standards for resident emergency ultrasound (EUS) competency assessment and to write a document that addresses the ACGME milestones. This article contains a historical perspective on resident training in EUS and a table of core skills deemed to be a minimum standard for the graduating EM resident. A survey summary of focused EUS education in EM residencies is described, as well as a suggestion for structuring education in residency. Finally, adjuncts to a quantitative measurement of resident competency for EUS are offered.     

Direct Observation for Assessing Emergency Medicine Core Competencies: Interpersonal Skills

The American Board of Medical Specialties described six core competencies considered essential elements of medical practice: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. In response, the Accreditation Council for Graduate Medical Education (ACGME) mandated that all residency programs assess trainees for the newly defined core competencies. Despite the mandate for including these six competencies in residency training, neither a specific curriculum nor a method to assess the outlined objectives has been developed by the ACGME. Instead, it is up to individual residency programs to document how they plan to incorporate and assess the core competencies in their programs. This article describes the potential use of direct observation to assess resident performance in the interpersonal skills core competency.     

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.     

Resident and fellow training in transfusion medicine

This article focuses on the design of transfusion medicine residency and fellowship training programs in the context of the Accreditation Commission for Graduate Medical Education (ACGME) competencies. Transfusion-specific examples of the six ACGME competencies are discussed, a transfusion medicine curriculum with designated training stages for specific curriculum elements is proposed, and examples of training activities are given. The authors also discuss transfusion service rotation design and how to build in graduated responsibility as training proceeds. Finally, methods for assessing the competency of transfusion medicine trainees and the effectiveness of the training program and teaching faculty are described. It is hoped that this article will provide a blueprint for how to design and implement a successful transfusion medicine residency and fellowship training program.     

Assessment of Communication and Interpersonal Skills Competencies

Excellent communication and interpersonal (C-IP) skills are a universal requirement for a well-rounded emergency physician. This requirement for C-IP skill excellence is a direct outgrowth of the expectations of our patients and a prerequisite to working in the increasingly complex emergency department environment. Directed education and assessment of C-IP skills are critical components of all emergency medicine (EM) training programs and now are a requirement of the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. In keeping with its mission to improve the quality of EM education and in response to the ACGME Outcome Project, the Council of Emergency Medicine Residency Directors (CORD-EM) hosted a consensus conference focusing on the application of the six core competencies to EM. The objective of this article is to report the results of this consensus conference as it relates to the C-IP competency. There were four primary goals: 1) define the C-IP skills competency for EM, 2) define the assessment methods currently used in other specialties, 3) identify the methods suggested by the ACGME for use in C-IP skills, and 4) analyze the applicability of these assessment techniques to EM. Ten specific communication competencies are defined for EM. Assessment techniques for evaluation of these C-IP competencies and a timeline for implementation are also defined. Standardized patients and direct observation were identified as the criterion standard assessment methods of C-IP skills; however, other methods for assessment are also discussed.     

Assessing clinical competence in physical medicine & rehabilitation residency programs

OBJECTIVE: Evaluation of resident clinical competence is a complex task. A multimodal approach is necessary to capture all of the dimensions of competence. Recent guidelines from the Accreditation Council for Graduate Medical Education delineate six general competencies that physicians should posses. Application of these guidelines presents challenges to residency program directors in defining educational experiences and evaluation methods. DESIGN: We surveyed 81 physical medicine and rehabilitation program directors regarding assessment tools used in their programs. Seventy-five percent responded. The most frequently used assessment tools included: In-training self-assessment examinations, faculty evaluations, direct observation, and conference participation. Program directors assigned the highest values to direct observation, faculty evaluations, self-assessment examinations, and oral examinations. RESULTS: Of the general competencies, more than 90% of program directors believed they did an adequate job rating dimensions of patient care, medical knowledge, professionalism, and communication skills. Approximately one-third, however, thought they did a less than fair job rating practice-based learning and improvement and systems-based practice. The majority of programs reported that they were able to identify a resident with difficulties during the first year of training, 44% within the first 6 months. Program directors reported that their residents spend a significant amount of their time with nurses and therapists during their inpatient rotations; however, this was not reflected in their evaluation practices, in which only one-fourth of programs reported the use of nurses and therapists in evaluating residents. CONCLUSIONS: Survey results indicate that physical medicine and rehabilitation program directors apply a variety of assessment tools in evaluating resident clinical competence. Although perceptions about the relative value of these tools vary, most programs report a high value to direct observation of residents by faculty. Of the six general competencies, program directors struggle the most with their evaluation of practice-based learning and improvement and systems-based practice.     

Outcome Assessment in Emergency Medicine—A Beginning: Results of the Council of Emergency Medicine Residency Directors (CORD) Emergency Medicine Consensus Workgroup on Outcome Assessment

This article is designed to serve as a guide for emergency medicine (EM) educators seeking to comply with the measurement and reporting requirements for Phase 3 of the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. A consensus workshop held during the 2006 Council of Emergency Medicine Residency Directors (CORD) "Best Practices" conference identified specific measures for five of the six EM competencies—interpersonal communication skills, patient care, practice-based learning, professionalism, and systems-based practice (medical knowledge was excluded). The suggested measures described herein should allow for ease in data collection and applicability to multiple core competencies as program directors incorporate core competency outcome measurement into their EM residency training programs.     

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.     

Assessing the ACGME General Competencies: General Considerations and Assessment Methods

The Accreditation Council for Graduate Medical Education's (ACGME's) general competency and outcome assessment initiative (i.e., the ACGME Outcome Project) is an effort to enhance residency education and accreditation effectiveness by increasing emphasis on educational outcomes. The Project is also a response to concerns about new graduates' ability to meet the demands of today's practice environment. The competencies emphasize learning in new domains (e.g., Practice-Based Learning and Improvement and Systems-Based Practice) and more traditional ones (e.g., Patient Care and Medical Knowledge). Outcome assessment will provide evidence of residency program educational effectiveness and information to guide improvement. This paper discusses the development and implementations of assessment methods appropriate to evaluate the performance of residents in each of the core competencies.     

Geriatric Emergency Medicine Educational Module: Abdominal Pain in the Older Adult

The Society for Emergency Medicine (SAEM) Geriatrics Task Force has created an instructional tool to address the complaint of abdominal pain in older adults presenting to the emergency department (ED). This is the first module in a comprehensive, web-based geriatric emergency medicine curriculum that will address common syndromes in older adults presenting to the ED. There is no formal, residency-based curriculum in geriatric emergency medicine and there is a paucity of geriatric Continuing Medical Education (CME) opportunities for practicing emergency physicians. The amount, quality, and convenience of geriatrics training available to emergency physicians is insufficient. This educational gap is particularly concerning given the ever-growing volume of older adult emergency patients. The Task Force chose to focus first on geriatric abdominal pain because a survey of emergency physicians in the mid 1990s found that it is one of the most difficult complaints to evaluate and manage. The module comprises of six clinical cases with a pre- and post-test. Together, these cases encompass the broad differential diagnosis for geriatric abdominal pain and the core medical knowledge pertaining to the subject. The modules will expose the learner, through either content or modeling, to the six Accreditation Council for Graduate Medical Education (ACGME) core competencies and to the Principles of Geriatric Emergency Medicine including rapid evaluation of functional status, communication skills, and consideration of the effect of polypharmacy and co-morbidity on the presenting complaint. This module will be available to residency programs as an "asynchronous educational session" via the Council of Emergency Medicine Residency Directors (CORD) website as well as to practicing emergency physicians via the SAEM and American College of Emergency Physicians (ACEP) websites.     

Definitions and Competencies for Practice-based Learning and Improvement

The Outcome Project is a long-term initiative by which the Accreditation Council for Graduate Medical Education (ACGME) is increasing emphasis on educational outcomes in the evaluation of residency programs. The ACGME initiated the Outcome Project to "ensure and improve the quality of graduate medical education." In order to assist program directors in emergency medicine (EM) to begin complying with components of the ACGME Outcome Project, the Council of Residency Directors in Emergency Medicine (CORD-EM) convened a consensus conference in March 2002 in conjunction with several other EM organizations. The working group for the competency of Practice-based Learning and Improvement (PBL) defined the components of PBL as: 1) analyze and assess practice experience and perform practice-based improvement; 2) locate, appraise, and utilize scientific evidence related to the patient's health problems and the larger population from which they are drawn; 3) apply knowledge of study design and statistical methods to critically appraise the medical literature; 4) utilize information technology to enhance personal education and improve patient care; and 5) facilitate the learning of students, colleagues, and other health care professionals in EM principles and practice. Establishing resident portfolios is a preferred method to chronicle resident competence in PBL. Traditional global evaluation of resident performance is de-emphasized. Checklist evaluation is appropriate for assessing any competency that can be broken down into specific behaviors or actions. 360-degree evaluation may be used to assess teamwork, communication skills, management skills, and clinical decision making. Chart-stimulated recall and record review are additional evaluation methods that can be used to assess resident competency in PBL. Simulations and models, such as computer-based scenarios, may be ideal for low-frequency but critical procedures.     

General Competencies Are Intrinsic to Emergency Medicine Training: A Multicenter Study

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) has promulgated six areas called General Competencies (GCs) that residency programs are required to evaluate. The authors sought to determine if these domains were an intrinsic part of emergency medicine (EM) residency training by using a global assessment evaluation device. METHODS: This was an observational, multicenter, cross-sectional study that compared GC acquisition between first-, second-, and third-year (EM1, EM2, and EM3) residents. Five postgraduate year (PGY) 1 to PGY 3 allopathic EM programs in Michigan participated. A global assessment form using a 1 through 9 ordinal scale with 86 scoring items was given to program directors for each resident in their programs. Analysis of variance (ANOVA) was used to compare the means between EM1, EM2, and EM3 scores. RESULTS: Five EM programs evaluated 150 residents. The GC scores were as follows: Patient Care: EM1 4.92, EM2 5.79, and EM3 6.40; Medical Knowledge: EM1 4.90, EM2 5.80, and EM3 6.46; Practice-based Learning and Improvement: EM1 4.60, EM2 5.48, and EM3 6.16; Interpersonal and Communication Skills: EM1 4.99, EM2 5.39, and EM3 6.01; Professionalism: EM1 5.43, EM2 5.68, and EM3 6.27; Systems-based Practice: EM1 4.80, EM2 5.48, and EM3 6.21. ANOVA showed statistically significant differences (p < 0.001) for all GCs. CONCLUSIONS: EM residents from several residency programs showed statistically significant progressive acquisition of the ACGME GCs using a global assessment device. This suggests that the GCs may be an intrinsic component in the training of EM residents.     

Defining and Evaluating Professionalism: A Core Competency for Graduate Emergency Medicine Education

Professionalism, long a consideration for physicians and their patients, is coming to the forefront as an essential element of graduate medical education as one of the six new core competency requirements of the Accreditation Council for Graduate Medical Education (ACGME). Professionalism is also integral to the widely endorsed Model of the Clinical Practice of Emergency Medicine (Model). Program directors have now been charged with implementing the new core competencies in training programs and to assess the acquisition of these competencies in their trainees. To assist emergency medicine (EM) program directors in this endeavor, the Council of Emergency Medicine Residency Directors (CORD-EM) held a consensus conference in March 2002. A focused Consensus Group addressed the specific core competency of professionalism during the course of this conference, and the results are highlighted in this article. The definition and curricular requirements relating to professionalism are highlighted, specific techniques for evaluating this core competency in EM are reviewed, and recommendations are provided regarding the most appropriate assessment method for EM programs.     

A Survey of Nonphysician Medical Screening Examinations in Academic Emergency Medicine

OBJECTIVES: To determine the proportions of U.S. emergency medicine (EM) residency programs that use nonphysicians to perform medical screening examinations (MSEs) in lieu of a physician evaluation. METHODS: This was a cross-sectional observational study consisting of a mail survey of the 109 base hospitals of accredited U.S. EM residency programs. Follow-up letters were sent twice to nonrespondents. Questions regarding ED demographics, the performance and structure of MSEs by physicians and nonphysicians, and the exact nature and purpose of such examinations were included. RESULTS: Ninety of 109 (83%) programs responded. Eighty-seven of the 90 programs (97%) perform MSEs on all patients presenting to the ED prior to discharge. Thirty-seven percent (33/90) perform nonphysician MSEs (NPMSEs) at least some of the time. Fifty percent (16/32) refer patients to an outside facility based on the result of the screening, and in 32% of cases the patient is not offered the choice of an ED evaluation. Seventy percent (19/27) at times refer patients, including uninsured patients, to a same-day clinic within their hospital system. Seven of 27 (26%) programs performing NPMSEs reported occasional adverse events, defined as two to 11 per year. Eight of 22 (36%) reported poorer clinical outcomes than expected from ED care as a result of the NPMSE, and 18 of 25 (72%) reported some degree of patient dissatisfaction. Two programs reported death as a result of NPMSEs. CONCLUSIONS: The use of NPMSEs is common and is frequently used as a basis for referring patients away from the ED without a physician examination. Using NPMSEs may be associated with adverse events, including patient dissatisfaction, morbidity, and possibly, mortality.     

Longitudinal Ultrasound Education Track Curriculum Implemented Within an Emergency Medicine Residency Program

Emergency Medicine residency programs offer ultrasound‐focused curricula to address Accreditation Council for Graduate Medical Education (ACGME) milestones. Although some programs offer advanced clinical tracks in ultrasound, no standard curriculum exists. We sought to establish a well‐defined ultrasound track curriculum to allow interested residents to develop advanced clinical skills and scholarship within this academic niche. The curriculum involves a greater number of clinical scans, ultrasound‐focused scholarly and quality improvement projects, enhanced faculty‐driven ultrasound focused didactics, and participation at a national ultrasound conference to receive certification. Successful ultrasound scholarly tracks can provide residents with the potential to obtain fellowships or competency beyond ACGME requirements.     

Integrating the Core Competencies: Proceedings from the 2005 Academic Assembly Consortium

The Accreditation Council for Graduate Medical Education mandated the integration of the core competencies into residency training in 2001. To this end, educators in emergency medicine (EM) have been proactive in their approach, using collaborative efforts to develop methods that teach and assess the competencies. The first steps toward a collaborative approach occurred during the proceedings of the Council of Emergency Medicine Residency Directors (CORD-EM) academic assembly in 2002. Three years later, the competencies were revisited by working groups of EM program directors and educators at the 2005 Academic Assembly. This report provides a summary discussion of the status of integration of the competencies into EM training programs in 2005.     

Curriculum content and evaluation of resident competency in clinical pathology (laboratory medicine): a proposal

Ten years have passed since the Graylyn Conference Report on Laboratory Medicine/Clinical Pathology training was issued. Over that time period, the Accreditation Council for Graduate Medical Education (ACGME) substantially revised the requirements for training programs, the American Board of Pathology (ABP) amended both the requirements and the time periods needed for certification, and the discipline itself, along with the broader discipline of pathology, evolved significantly. Recently, a curriculum proposal in anatomic pathology was published as a potential template to be used by training programs to help meet these new and evolving needs. Toward the same end, the Academy of Clinical Laboratory Physicians and Scientists has now developed a template for a curriculum in clinical pathology (laboratory medicine), taking into account newly designated and revised areas of residency core competency, the alterations in training requirements promulgated by the ACGME and ABP, and the rapidly developing nature of the discipline itself. The proposed clinical pathology curriculum defines goals and objectives for training, provides guidelines for instructional methods, and gives examples of how outcomes can be assessed. This curriculum is presented as a potentially helpful outline for use by pathology residency training programs.