Integrating the Accreditation Council for Graduate Medical Education Core competencies into the model of the clinical practice of emergency medicine

In response to public pressure for greater accountability from the medical profession, a transformation is occurring in the approach to medical education and assessment of physician competency. Over the past 5 years, the Accreditation Council for Graduate Medical Education (ACGME) has implemented the Outcomes and General Competencies projects to better ensure that physicians are appropriately trained in the knowledge and skills of their specialties. Concurrently, the American Board of Medical Specialties, including the American Board of Emergency Medicine (ABEM), has embraced the competency concept. The core competencies have been integral in ABEM's development of Emergency Medicine Continuous Certification and the development of the Model of Clinical Practice of Emergency Medicine (Model).¹ ABEM has used the Model as a significant part of its blueprint for the written and oral certification examinations in emergency medicine and is fully supportive of the effort to more fully define and integrate the ACGME core competencies into training emergency medicine specialists.To incorporate these competencies into our specialty, an Emergency Medicine Competency Taskforce (Taskforce) was formed by the Residency Review Committee–Emergency Medicine to determine how these general competencies fit in the Model.¹ This article represents a consensus of the Taskforce with the input of multiple organizations in emergency medicine. It provides a framework for organizations such as the Council of Emergency Medicine Residency Directors (CORD) and the Society for Academic Emergency Medicine to develop a curriculum in emergency medicine and program requirement revisions by the Residency Review Committee–Emergency Medicine. In this report, we describe the approach taken by the Taskforce to integrate the ACGME core competencies into the Model. Ultimately, as competency-based assessment is implemented in emergency medicine training, program directors, governing bodies such as the ACGME, and individual patients can be assured that physicians are competent in emergency medicine.     

A survey of academic departments of emergency medicine regarding operation and clinical practice

STUDY OBJECTIVE: To survey academic departments of emergency medicine concerning their operation and clinical practice. METHODS: A survey was mailed to the chairs of all 56 academic departments of emergency medicine in the United States requesting information concerning operations and clinical activity in budget year 1997-1998 compared with 1995-1996. These results were then compared with a similar survey conducted in the fall of 1996, examining the 1995-1996 academic year compared with the 1994-1995 academic year. RESULTS: Forty-one (73%) academic departments of emergency medicine responded. For 1997-1998, compared with 1995-1996, 24 (59%) academic departments of emergency medicine reported an increase in emergency department patient volume; 10 (24%) reported a decrease. Twenty-four (51%) academic departments of emergency medicine reported an increase in ED patient severity, whereas 7 (15%) reported a decrease. Twenty-five (61%) academic departments of emergency medicine reported an increase in net clinical revenue for emergency medicine services, and 9 (22%) reported a decrease. Only 9 (22%) academic departments of emergency medicine reported other academic departments within their university/medical center aggressively directing patients away from the ED compared with 14 (30%) in the previous study. The percentage of academic departments of emergency medicine using midlevel providers remained essentially the same over time (68% versus 66%). In both studies, midlevel providers were used most commonly in a fast-track setting. Only 37% of academic departments of emergency medicine reported having an observation unit; staffing in all cases was by emergency physicians. Since the last survey, 38 (93%) academic departments of emergency medicine reported their medical center or hospital negotiating with managed care organizations to provide services. Unfortunately, only 41% of chairs were involved in these discussions. Between January 1, 1997, and the 1998 fall survey, 29% of academic departments of emergency medicine reported their university merging with another university system, and 19% reported such mergers being discussed. Similarly, between January 1, 1997, and fall 1998, 22% of academic departments of emergency medicine reported their institution merging with a private entity, whereas 16% reported ongoing discussions. CONCLUSION: Academic departments of emergency medicine have experienced some encouraging trends: an increase in ED patient volume, patient severity, and net clinical revenue during the study period. Midlevel providers continue to be used primarily in fast-track areas of EDs. An area of potential growth for academic departments of emergency medicine is observation medicine, because only one third of academic departments of emergency medicine have such a unit. Academic medical centers have experienced a significant increase in merger activity during the study period.     

An emergency medicine clinical problem-solving system

The availability of complete, accurate, and current medical information is an important aspect of clinical problem solving. As the body of medical information grows and increasingly is reformatted into problem-oriented references, information processing by physicians will grow in importance. The most popular clinical problem-solving method, the Weed problem-oriented medical record, primarily records information; it does not provide an explicit information-processing model. An emergency medicine clinical problem-solving system containing information recording and processing methodologies is presented. The information processing methodology of this system is highlighted.     

Sequential clinical trials in emergency medicine

In a traditional clinical trial, a fixed number of patients are evaluated before the data are analyzed. This has the disadvantage that more patients may be enrolled than are necessary to achieve a statistically significant result. Sequential statistical techniques provide a method for the analysis of clinical trials so that a reliable result is obtained with a minimum number of patients. In a sequential trial, the data are analyzed after each patient's outcome is known, and the trial is halted as soon as treatment efficacy or lack thereof is demonstrated. This study was undertaken to confirm the advantages of sequential statistical techniques over conventional fixed-sample-size statistical techniques for the analysis of clinical trials. Using sequential techniques, we conducted computer simulations of two fixed-sample-size clinical studies from the literature - a trial of hepatitis B vaccine in homosexual men (N Engl J Med 1980;303:833-841) and a trial of the pneumatic antishock garment in hypotensive patients with penetrating abdominal trauma (Ann Emerg Med 1987;16:653-658). In the trial simulations, patients were randomly assigned to the control and test groups, their outcomes were determined randomly according to the frequency of outcomes observed in the actual studies, and the simulated sequential studies were continued until conclusions were reached. Thousands of possible realizations of each trial were simulated; thus, the distribution of required patient numbers was determined.(ABSTRACT TRUNCATED AT 250 WORDS)     

Computerized tracking of emergency medicine resident clinical experience

Although we commonly assume that because residents spend a given number of months in the emergency department they achieve adequate exposure to all necessary clinical entities, this has never been shown. We suspect, rather, that great variability exists among residents in the number and variety of patients they see; and that with respect to the ED, there are important diagnoses that are rare or absent in the clinical pathology of a training program. To confirm these hypotheses, we implemented a computerized system of recording patients and diagnoses managed in the ED by the 33 residents of the University of Illinois Affiliated Hospitals Emergency Medicine Residency. We collected data for nine months and accumulated 2,152 shifts of clinical experience. These data confirm our hypotheses. We found that senior residents managed an average of 11.9 +/- 2.3 patients per ten-hour shift, but the quickest resident saw almost twice as many patients as the slowest. Junior residents saw fewer patients, 8.5 +/- 1.4 patients per shift, but maintained a twofold difference between the fastest and slowest. Furthermore, there are important diagnoses that present too rarely for each resident to become facile in their management. We found that 22.7% of the 554 diagnoses listed in the Emergency Medicine Core Content never once presented to the ED. An additional 34.7% of these diagnoses did present, but so rarely that each resident could not possibly manage one case during a residency. The Length of Training Report of the American College of Emergency Physicians provides objective guidelines for the number of encounters a resident should have with 283 clinical entities. In this study, residents fell short of these guidelines with 50.5% of diagnoses. While absolute quantity of exposure does not assure competence in management, we recommend that each residency monitor the experience of its residents. This allows a residency to change its curriculum to make optimum use of available pathology, as well as to supplement deficiencies in clinical experience with case simulations.     

The relevance to clinical practice of the certifying examination in internal medicine

Objective: To determine the relevance of the initial certifying examination to the practice of internal medicine and the suitability of items used in initial certification for recertification. Design: Using a matrix-sampling approach, items from the 1991 Certifying Examination were assigned to two sets of judges: directors of the American Board of Internal Medicine (ABIM) and practicing general internists. Each judge rated the relevance of items on a five-point scale. Participants: 54 current or former directors of the ABIM and 72 practicing general internists; practitioners were nominated by directors and their ratings were included if they spent > 80% of their time in direct patient care. Results: The directors’ mean rating of all 576 items was 3.98 (SD=0.62); the practitioners’ mean rating was 4.11 (SD=0.82). The directors assigned to 27 items ratings of less than 3 and the practitioners assigned to 42 items ratings of less than 3; seven of these items received low ratings from both groups. There were differences in the two groups’ ratings of the relevance of various medical content categories, but the mean rating of core items was higher than that of noncore items and the mean rating of items testing clinical judgment was higher than that of items testing knowledge or synthesis. Conclusions: These findings suggest that the initial certifying examination is relevant to clinical practice and that many of the examination items are suitable for use in recertification. Differences in perception appear to exist between practitioners and directors, and the use of practitioner ratings is likely to be a routine part of judging the suitability of items for Board examinations in the future.     

Interdisciplinary training: hospital dental general practice/emergency medicine

The interaction between the residency training program in hospital dental general practice and emergency medicine at The Medical College of Pennsylvania is discussed. The contribution by the emergency medicine resident to the training of the dental resident and the role of the dental resident in the education of the emergency medicine resident are described in detail. Methods for enhancing this unique relationship between two departments are presented.     

循证医学与心血管病临床实践

循证医学(evidenee based medicine,EBM)指遵循科学证据的临床医学[1].1992年由Guyatt领导的加拿大McMaster.大学临床流行病教学组首次在JAMA上提出循证医学概念[2],随后由被称为"循证医学之父"的Sackect等出版专著陈述循证医学含义及方法[3].