Integrating emergency medicine principles and experience throughout the medical school curriculum: why and how

The management of acutely ill and injured patients is an essential component of medical student education, yet the formal integration of emergency medicine (EM) into the medical school curriculum has progressed slowly since the inception of the specialty. Medical student interest and the number of resident positions in the National Resident Matching Program are higher than any time in the past, yet students often find access to EM faculty and clinical experience limited to a fourth-year rotation. Incorporating EM into all years of the undergraduate medical student curriculum can offer unique educational experiences and enhance exposure to the necessary and recommended knowledge and skills students must attain prior to graduation. Academic emergency physicians (EPs) should advocate our specialty's importance in their medical school curricula using a proactive approach and actively involve themselves in medical student education at all stages of training. The goals of this article are to describe several approaches for EM faculty to expand medical student exposure to the specialty and enhance student experiences in the core principles of EM throughout the undergraduate medical curriculum.     

Developing a third-year emergency medicine medical student curriculum: a syllabus of content

Emergency medicine (EM) educators have published several curricular guides designed for medical student rotations and experiences. These guides primarily provided brief overviews of opportunities to incorporate EM into all 4 years of the medical student curriculum, with one specific to the fourth year. However, there are no published guidelines specific to third-year medical students rotating in EM. Given the differences between third-year and fourth-year students in terms of clinical experience, knowledge, and skills, the Clerkship Directors in Emergency Medicine (CDEM) established the Third-year EM Medical Student Curriculum Work Group to create a third-year curriculum. The work group began this process by developing consensus-based recommendations for the content of a third-year medical student EM rotation, which are presented in this syllabus.     

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.     

Advanced Opportunities for Student Education in Emergency Medicine

Many medical students are excited about emergency medicine (EM) following a standard clerkship and seek out additional learning opportunities. An advanced EM elective may accomplish several educational goals, including development of clinical skills in evaluating the undifferentiated patient, broader exploration of the field of EM, and more focused study of one particular aspect of EM. Previously cited examples include pediatric EM, medical toxicology, occupational medicine, sports medicine, and EM research. Numerous other EM specialty courses for senior medical students are emerging, as reflected in the “Undergraduate Rotations” listings on the Society for Academic Emergency Medicine. A few examples drawn from the list include emergency ultrasound, international EM, wilderness medicine, disaster medicine, geriatric EM, and hyperbaric medicine. Educators aspiring to develop, or in the process of developing, an advanced EM elective may benefit from a brief overview of necessary course considerations, including didactic format, the clinical role of the medical student in the emergency department, and involvement with patient procedures. Suggestions are made regarding additional educational opportunities, including follow‐up of patients seen in the emergency department and development of an emergency department radiology case file. This article also addresses several related concerns, including suggested prerequisites, administration and cost considerations, appropriate didactic topics, and methods for evaluating students. Several EM subspecialty areas, namely pediatric EM, medical toxicology, and out‐of‐hospital care, are specifically discussed. Formal advanced cardiac life support training is also often included in an advanced EM elective and is briefly discussed. The overall intent of this article is to provide medical student educators with resources and ideas to assist them in developing a unique advanced EM elective.     

The Community Preceptor Crisis: Recruiting and Retaining Community-Based Faculty to Teach Medical Students—A Shared Perspective From the Alliance for Clinical Education

Issue: Community-based instruction is invaluable to medical students, as it provides “real-world” opportunities for observing and following patients over time while refining history taking, physical examination, differential diagnosis, and patient management skills. Community-based ambulatory settings can be more conducive to practicing these skills than highly specialized, academically based practice sites. The Association of American Medical Colleges and other national medical education organizations have expressed concern about recruitment and retention of preceptors to provide high-quality educational experiences in community-based practice sites. These concerns stem from constraints imposed by documentation in electronic health records; perceptions that student mentoring is burdensome resulting in decreased clinical productivity; and competition between allopathic, osteopathic, and international medical schools for finite resources for medical student experiences. Evidence: In this Alliance for Clinical Education position statement, we provide a consensus summary of representatives from national medical education organizations in 8 specialties that offer clinical clerkships. We describe the current challenges in providing medical students with adequate community-based instruction and propose potential solutions. Implications: Our recommendations are designed to assist clerkship directors and medical school leaders overcome current challenges and ensure high-quality, community-based clinical learning opportunities for all students. They include suggesting ways to orient community clinic sites for students, explaining how students can add value to the preceptor's practice, focusing on educator skills development, recognizing preceptors who excel in their role as educators, and suggesting forms of compensation.     

Political and Budget Issues Associated with Educating Medical Students

The senior year provides an excellent opportunity for medical students to experience the specialty of emergency medicine for career exploration and skill development. This educational experience can provide the medical school with the means to meet the Liaison Committee on Medical Education recommendation that all graduating students should be capable of handling emergencies. The senior rotation may be a mandatory or elective experience. It is in the emergency department that students can gain experience in evaluating the undifferentiated patient and may refine their history and physical examination skills. They have the chance to become adept at rapid decision making in the diagnosis and stabilization of patients. This paper outlines the components of a typical four‐week rotation, such as the orientation session, the didactic program, the clinical experience, the evaluation of students, the faculty, and the educational experience. Strategies for implementing both didactic and clinical components of the curriculum are provided. The managerial role of the clerkship director is introduced. Suggestions for assuming administrative and educational responsibility for an existing course are made. A guide to the development and implementation of a new course is described, in which the course objectives and prerequisites must be set, the core didactic curriculum formulated, the clinical experience defined, and a system of evaluation and feedback developed. Students generally enjoy their emergency medicine experience as it is often their first opportunity to assume primary responsibility for patient care. Clerkship directors can develop their leadership skills in managing a major educational component of the senior year that may prove beneficial in developing a career in the field of medical education.     

A replicable model of a health literacy curriculum for a third-year clerkship

Contrary to recommendations from national medical organizations, medical school education often fails to train students to interact effectively with patients with limited health literacy. The objectives of a new health literacy curriculum in a family medicine clerkship were to increase students' knowledge of health literacy and develop comfort with specific communication skills. Instructional strategies included lectures, practice with standardized patients (SPs), and a facilitated discussion board. At the end of the first year of the curriculum, there was a statistically significant increase in students' knowledge of health literacy. During the final testing with SPs, students achieved high scores for health literacy related communication skills. The curriculum is replicable at other universities and was an effective and efficient way for medical students to learn about health literacy and to acquire valuable skills to improve their patients' understanding of health information.     

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.     

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.     

An alternative clerkship model for ambulatory training: An interdisciplinary primary care experience

The Primary Care Clerkship of George Washington University is the only required ambulatory experience in the medical school curriculum. This 6‐week clerkship for third‐year medical students blends exposure to several primary care disciplines: family practice, internal medicine, pediatrics, and geriatrics. In addition to addressing epidemiologically common conditions, the curricular goals emphasize primary care concerns such as the doctor‐patient relationship, clinical epidemiology, the natural history of disease, appropriate and cost‐effective use of resources and consultants, quality assessment, screening strategies, and critical thinking skills. Each student is assigned two primary preceptors for the entire clerkship and spends 80% of his or her time in patient care. Typically, one of each student's preceptors works in the Medical Center's faculty practice; the other is a physician in private practice or in an inner‐city clinic for the medically underserved and homeless. Students may also work with geriatricians in nursing homes and on home visits in the Washington, DC area.     

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.     

Medical students’ needs for feedback from residents during the clinical clerkship year

Feedback from residents may be an important component of the learning process for medical students in the clerkship year. In this study, we investigated what kind of feedback medical students in the clerkship year desired from residents and whether these needs changed over the course of the clerkship year. Over the course of 1 year, 69 students from one medical school class participated in meetings in which the nominal group technique was used to identify their feedback needs. Six students were also individually interviewed. Feedback needs early in the clerkship year were closely linked with students’ needs for goals clarification. As the year progressed, students required less communication from residents regarding expectations and more feedback on specific skills, notably physical examination skills, clinical skills, or both and written communication. Feedback either early or at a midpoint in the clerkship appeared to be an important need. Both positive and negative feedback were frequently mentioned. These results appear to validate theoretical guidelines for feedback previously described in the medical education literature.     

Teaching and evaluation of physical examination skills on the surgical clerkship

It is presumed that graduating medical students possess adequate physical examination skills, although they are rarely evaluated during the clinical years. In this study we assessed the physical examination skills of third‐year medical students at the beginning and end of a surgical clerkship and investigated the effect of clerkship experiences and formal feedback on maturation of these skills. Sixty‐seven third‐year students completed a course on physical examination during their second year of medical school and achieved a 90% performance level on a physical examination performed on a patient instructor. This group subsequently performed a focused physical examination (chest, abdomen, groin [hernia], and external genitalia) during Week 1 and Week 6 of a 6‐week third‐year surgical clerkship. The physical examination was observed and evaluated using a 38‐item checklist; feedback was provided immediately after the first examination. Pretest performance was significantly poorer than that achieved in the second‐year course. Statistically significant improvement was noted from pretest to posttest for all areas except the external genitalia examination. Students in later rotations in the academic year did not perform significantly better than students in early rotations. We concluded that deterioration of learned physical examination skills occurs from the preclinical to the clinical years and that this deficiency is not corrected by clerkship experiences. Evaluation and feedback during the clerkship resulted in improvements in skills back to the levels demonstrated during the second year.     

Global Health and Emergency Care: An Undergraduate Medical Education Consensus‐based Research Agenda

Global emergency medicine (EM) is a rapidly growing field within EM, as evidenced by the increasing number of medical students desiring global health and emergency care experiences. Despite this growing popularity, little is known of the effect of undergraduate medical education in global health on learners and patients in the United States and abroad. During the 2013 Academic Emergency Medicine consensus conference, a group of leading medical school educators convened to generate a research agenda on priority questions to be answered in this arena. This consensus‐based research agenda is presented in this article.     

Computerized literature searching on a core internal medicine clerkship

The use, acceptance, and benefits of computerized literature searching by medical students during an internal medicine clerkship were evaluated. A year‐long prospective comparison of two student groups was performed in a community‐based medical school with five clinical sites. All third‐year medical students were required to supply two nontextbook references for each assigned patient evaluation during their core medicine clerkship. All 37 students enrolled in the second and fourth quarters of the academic year (Group 1) used the computer bibliographic retrieval service BRS Colleague® through five local modern‐equipped terminals to obtain their references. The 40 students in the first and third quarters (Group 2, controls) obtained their references without doing computer searches themselves. All Group 1 students felt capable of using the system, and 96% felt the service was helpful to their clinical learning. When compared with the control group, students using the computer search spent less time looking for articles (23 min vs. 122 min) and found more useful references about therapeutics. The mean cost per student search was $10.64. These data indicate that computerized literature searching is easily learned, used, and accepted by third‐year medical students. Time is saved accessing the medical literature. Computer literature search training should be an integral part of today's medical student curriculum.