An emergency medical services curriculum for emergency medicine residencies

Knowledge and experience in emergency medical services (EMS) are essential objectives for residency training in emergency medicine (EM). Although a need exists for competent physician EMS leaders, opportunities for educating emergency physicians in this aspect of emergency care have been few. We describe a curriculum for training EM residents in EMS. The purpose of this training is to assure competency in both on-line and off-line medical control. The former requires a working knowledge of the local system policies and the ability to respond appropriately to paramedic radio calls. Additional education prepares the resident for a much broader role in EMS, including off-line medical control.     

Medical expertise as a critical influencing factor on the length of stay in the ED: A retrospective cohort study

Overcrowding in the emergency departments (ED) is a significant issue associated with increased morbidity and mortality rates as well as decreased patient satisfaction. Length of stay (LOS) is both a cause and a result of overcrowding. In Israel, as there are few emergency medicine (EM) physicians, the ED team is supplemented with doctors from specialties including internal medicine, general surgery, orthopedics etc. Here we compare ED length of stay (ED-LOS), treatment time and decision time between EM physicians, internists and general surgeons.A retrospective cohort study was conducted examining the Emergency Department length of stay (ED-LOS) for all adult patients attending Sheba Medical Center ED, Israel, between January 1st, and December 31st, 2014. Using electronic medical records, data was gathered on patient age, sex, primary ED physician, diagnosis, eventual disposition, treatment time and disposition decision time. The primary outcome variable was ED-LOS relative to case physician specialty and level (ED, internal medicine or surgery; specialist or resident). Secondary analysis was conducted on time to treatment/ decision as well as ED-LOS relative to patient classification variables (internal medicine vs surgical diagnosis). Specialists were compared to specialists and residents to residents for all outcomes.Residents and specialists in either EM, internal medicine or general surgery attended 57,486 (51.50%) of 111,630 visits to Sheba Hospital''s general ED. Mean ED-LOS was 4.12 ± 3.18 hours. Mean treatment time and decision time were 1.79 ± 1.82 hours, 2.84 ± 2.17 hours respectively. Amongst specialists, ED-LOS was shorter for EM physicians than for internal medicine physicians (mean difference 0.28 hours, 95% CI 0.14–0.43) and general surgeons (mean difference 0.63 hours, 95% CI 0.43–0.83). There was no statistical significance between residents when comparing outcomes.Increasing the number of EM specialists in the ED may support efforts to decrease ED-LOS, overcrowding and medical errors whilst increasing patient satisfaction and outcomes.     

Alumni perspectives comparing a general internal medicine program and a traditional medicine program

Objective:To evaluate a primary care internal medicine curriculum, the authors surveyed four years (1983–1986) of graduates of the primary care and traditional internal medicine residency programs at their institution concerning the graduates’ preparation. Design:Mailed survey of alumni of a residency training program. Setting:Teaching hospital alumni. Subjects/methods:Of 91 alumni of an internal medicine training program for whom addresses had been found, 82 (90%) of the residents (20 primary care and 62 traditional) rated on a five-point Likert scale 82 items for both adequacy of preparation for practice and importance of training. These items were divided into five groups: traditional medical disciplines (e.g., cardiology), allied disciplines (e.g., orthopedics), areas related to medical practice (e.g., patient education), basic skills and knowledge (e.g., history and physical), and technical procedures. Main results:Primary care residents were more likely to see themselves as primary care physicians versus subspecialists (84% versus 45%). The primary care graduates felt significantly better prepared in the allied disciplines and in areas related to medical practice (p<0.01). There was no significant difference overall in perceptions of preparation in the traditional medical disciplines, basic skills and knowledge, and procedures. The same results were obtained when the authors looked only at graduates from the two programs who spent more than 50% of their time as primary care physicians versus subspecialists. There was no significant difference between the two groups in the perceived importances of these areas to current practice. Conclusions:These results suggest that the primary care curriculum has prepared residents in areas particularly relevant to primary care practice. Additionally, these individuals feel as well prepared as do their colleagues in the traditional medical disciplines, basic skills and knowledge, and procedural skills. Received from the Division of General Internal Medicine, Brown University Program in Medicine, and the Rhode Island Hospital, Providence, Rhode Island. Dr. Kiel is a Henry J. Kaiser Family Foundation Faculty Scholar in general internal medicine. Address correspondence and reprint requests to General Internal Medicine, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903.     

Emergency drills in a pediatric residency training program

A variety of common pediatric emergencies were created in anesthetized cats to provide pediatric house officers and practicing physicians with an opportunity to refine diagnostic and management skills in a controlled environment under supervision. We describe the format of the animal model drill, outline protocols for stimulating pediatric critical care emergencies, and present preliminary evaluation data from a continuing medical education workshop and from house staff drills regarding the efficacy of the program.     

A comparison between the efficacy of lectures given by emergency and non-emergency physicians in an international emergency medicine educational intervention

OBJECTIVE: The Tuscan Emergency Medicine Initiative is an international collaboration designed to create a sustainable emergency medicine training and qualification process in Tuscany, Italy. Part of the program involves training all emergency physicians currently practicing in the region. This qualification process includes didactic lectures, clinical rotations and practical workshops for those with significant emergency department experience. Lectures in the didactic portion were given by both emergency medicine (EM) and non-EM faculty. We hypothesized that faculty who worked clinically in EM would give more effective lectures than non-EM faculty. METHODS: Fifty-one emergency physicians from the hospitals surrounding Florence completed the course, which included 48 one-hour lectures. Twenty lectures were given by practicing emergency physicians and 28 were given by non-EM faculty. Participants completed an evaluation at the end of each session using a 5-point Likert scale describing the pertinence of the lecture to EM, the efficacy and clarity of the presentation, the accuracy of the information and the didactic ability of the lecturer. RESULTS: A mean of 38.5 evaluations was completed for each lecture. Every factor was significantly higher for lectures given by EM faculty: the pertinence of the lecture to EM (4.46 vs. 4.16, p < 0.001), the efficacy of the faculty (4.10 vs. 3.91, p < 0.001), the accuracy of the lecture content (4.16 vs 3.96, p < 0.001), and the didactic ability of the instructors (4.02 vs. 3.85, p = 0.001). CONCLUSIONS: When teaching EM, evaluations of lectures in this training intervention were higher for lectures given by EM faculty than by non-EM faculty.     

Hepatitis B prevalence in emergency physicians

The seriousness of hepatitis B (HBV) as an occupational hazard to health care workers is well documented. The prevalence of serologic markers for this disease in the general US population is less than 5%, but in medical and dental workers it is significantly higher: 16% in general dentists, 28% in surgeons, 23% in anesthesia personnel, and 30% in emergency department nurses. This study, done under the auspices of the American College of Emergency Physicians (ACEP), focused on the prevalence of HBV markers in emergency physicians. Twenty-five percent of the 1983 ACEP Scientific Assembly attendees participated in the serosurvey. Physicians already vaccinated against hepatitis B were excluded. The majority of participants (58%) were community emergency physicians between 30 and 39 years of age who had six or more years in emergency medicine. A total of 94% of the physicians indicated no prior history of hepatitis, and of these 13.1% had serologic markers for HBV. Including the 10 physicians with both HBV markers and history of hepatitis, the overall prevalence for markers in this study was 15.5%. This prevalence was five times greater than the general population. Emergency physicians should be considered a high-risk group for HBV infection.     

Emergency medicine management of the geriatric patient: an educational program for medical students

This article describes the experience of fourth-year medical students participating in a geriatric education program integrated into a 4-week emergency medicine student clerkship. Between July 2002 and April 2003, all students in this required clerkship participated in a geriatric educational program consisting of a small group discussion of medical and psychosocial issues of older adult emergency department (ED) patients. Students used learned skills to evaluate older adult ED patients for medical and psychosocial issues and later followed up with these patients by telephoning them at their homes or visiting them in the hospital. Students tracked their evaluations of the medical problems, functional abilities, and social supports of patients in the ED. Students also noted when their assessments resulted in the acquisition of new skills or knowledge and when their evaluation of geriatric syndromes resulted in a change of the patient care plan. Seventy-seven students evaluated 217 patients in the ED, of whom 167 (77%) received a follow-up visit or phone call. Students documented learning new skills while caring for 80 (48%) of the older adult patients. Qualitative survey responses from students indicated that students had increased understanding of the importance of assessing functional status and social supports and providing interdisciplinary care. Integrating geriatric education modules into existing emergency medicine clerkships is an effective method to expand the geriatric curriculum in medical schools and to emphasize the importance of geriatric assessment and syndromes in emergency care.     

Expansion of emergency medicine's responsibilities for preclinical education of medical students

Many medical schools have required emergency medicine courses for freshmen medical students, usually through participation in BLS (basic life support) or EMT activities. For several years students at our institution have participated in a required emergency medical technician-ambulance grade (EMT-A) course. While retaining much of the material presented in that original EMT-A course, the course has now been expanded to serve as the medical students' introduction to clinical medicine. This expansion resulted from the belief that emergency medicine provides initial patient contact in the presence of a faculty uniquely suited to introduce the broad domain of clinical medicine to the medical student. Emergency physicians, more than any other specialists, must possess the ability to obtain an incisive history promptly, perform an accurate physical examination, and arrive at an assessment with limited laboratory and radiologic data. Initial access to the clinical education of medical students provides the opportunity to direct their efforts in a prioritized fashion, and thus helps to organize their thought processes for further development as clinicians. Departments of emergency medicine should be willing to accept this incremental responsibility for the introduction of the medical student to the clinical and laboratory assessment of patients.     

Survey of medicine/pediatrics residency training programs

The American Board of Internal Medicine and the American Board of Pediatrics agreed in 1967 to create combined medicine/pediatrics residency training programs. These programs span four years and provide 24 months of training in each discipline, leading to Board eligibility in both. Little is known about their curricula because there is no separate residency review committee to critique the current programs. The directors of the 65 current programs were surveyed by mail. Fifty-seven (88%) responded to questions about: lengths of time programs had been in operation, attitudes toward quality of residents, program structures and curricula, and performances of graduates taking the Boards. More than half of the programs were established after 1980. Forty of the programs’ graduates have passed the Medicine Boards, and 48 have passed the Pediatrics written Boards. Most programs were structured to have residents switch specialties every six months. Program Directors, both in Medicine and in Pediatrics, rated the quality of combined program residents the same as or slightly better than that of residents in non-combined programs. Medicine/pediatrics residencies have become a successful and important source of training for generalists’ careers in and outside of academe, and in both primary and specialty care. Received from the Department of Medicine and the Department of Pediatrics, West Virginia University, Morgantown, West Virginia. Presented in part at the session for Medicine/Pediatrics program directors at the Association of Program Directors in Internal Medicine in New Orleans, October 26, 1986.     

The relationship between features of residency training and ABIM certifying examination performance

The purpose of this study was to provide data concerning the relationship between features of residency training and a test of cognitive achievement gathered at the end of residency. To accomplish this, data collected in the late 1970s by three national organizations were joined and analyzed with the aid of experts in internal medicine. Although graduate medical education has evolved since this information was gathered, it does provide a baseline for assessing the impact of changes on the cognitive skills of residents. The findings suggest that better program performance on the examination is associated with attracting more knowledgeable residents to begin with and that programs are able to maintain the advantage of their residents throughout training. Moreover, program characteristics have an impact on the cognitive skills of residents over and above what would be predicted by test scores at the end of medical school. Programs with better examination performance tend to provide residents an extensive, well-supervised educational experience stressing ambulatory care. Received from the American Board of Internal Medicine, Philadelphia, Pennsylvania. Supported by The American Board of Internal Medicine. This report does not necessarily reflect the opinions or policies of the American Board of Internal Medicine.     

Preventing communication errors in telephone medicine

Errors in telephone communication can result in outcomes ranging from inconvenience and anxiety to serious compromises in patient safety. Although 25% of interactions between physicians and patients take place on the telephone, little has been written about telephone communication and medical mishaps. Similarly, training in telephone medicine skills is limited; only 6% of residency programs teach any aspect of telephone medicine. Increasing familiarity with common telephone challenges with patients may help physicians decrease the likelihood of negative outcomes. We use case vignettes to highlight communication errors in common telephone scenarios. These scenarios include giving sensitive test results, requests for narcotics, managing ill patients who are not sick enough for the emergency room, dealing with late-night calls, communicating with unintelligible patients, and handling calls from family members. We provide management strategies to minimize the occurrence of these errors.     

Fulfilling the Promise of Hospital Medicine: Tailoring Internal Medicine Training to Address Hospitalists’ Needs

Categorical internal medicine (IM) residency training has historically effectively prepared graduates to manage the medical needs of acutely ill adults. The development of the field of hospital medicine, however, has resulted in hospitalists filling clinical niches that have been traditionally ignored or underemphasized in categorical IM training. Furthermore, hospitalists are increasingly leading inpatient safety, quality and efficiency initiatives that require understanding of hospital systems, multidisciplinary care and inpatient quality assessment and performance improvement. Taken in this context, many graduating IM residents are under-prepared to practice as effective hospitalists. In this paper, we outline the rationale for targeted training in hospital medicine and discuss the content and methods for delivering this training. This paper has not been presented at any conferences. This work was not funded by a grant.     

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.     

Teaching women’s health skills

OBJECTIVE: This study assesses the readiness of academic general internists to perform and precept a commonly utilized women's health examination, and procedural and management skills. DESIGN: Full-time faculty from divisions of general internal medicine and departments of family practice in 9 states reported their encounter frequency with, comfort precepting, and the importance they ascribe to several examination, procedural, and management skills relevant to women's health care; and their attitudes toward performing the pelvic exam and obtaining a Pap smear. MEASUREMENTS AND MAIN RESULTS: A total of 331 general internal medicine physicians (GIMs) and 271 family medicine physicians (FPs) completed questionnaires, with response rates of 57% and 64%, respectively. More than 90% of GIMs and FPs indicated they were confident precepting the breast and Pap/pelvic examinations. A relatively small percentage of GIMs expressed confidence precepting the management of dysfunctional uterine bleeding (22%), initiating Depo-Provera (21%), and initiating oral contraceptives (45%), while a substantially larger percentage indicated that these skills were important to primary care practice (43%, 44%, and 85%, respectively). Although GIMs indicated they were confident precepting the Pap/pelvic exam, they were less likely than FPs to agree with the following statements: "Performing routine Pap smears is a good use of my time" (GIMs 65%, FPs 84%); "It is a waste of health care dollars for primary care physicians to refer patients to gynecologists for routine Pap/pelvic exams" (GIMs 69%, FPs 90%); "I feel very well trained to do a routine bimanual exam" (GIMs 71%, FPs 98%), and "The clinic where I practice is well equipped to do a Pap smear" (GIMs 78%, FPs 94%). CONCLUSIONS: Although most academic GIMs are confident precepting the breast and pelvic examination, only a minority are confident precepting the management of dysfunctional uterine bleeding, initiating Depo-Provera, and initiating oral contraceptives. These findings suggest that a number of academic GIMs may not be prepared or willing to perform or precept important women's health skills.     

Caractéristiques des patients admis en médecine interne dans 18 hôpitaux français en aval des urgences et organisation de ces services : enquête transversale de la SNFMI (groupe d’étude SiFMI) en 2015

IntroductionPatients admitted from emergency units represent a large portion of the population in internal medicine departments. The aim of this study is to identify characteristics of patients and organization of these departments.MethodsBetween June 29th and July 26th 2015, voluntary internal medicine departments from the SiFMI group prospectively filled anonymized internet forms to collect data of each patients admitted in their ward from emergency units, during seven consecutive days.ResultsThree hundred and sixty-five patients from emergency departments were admitted in 18 internal medicine inpatients departments, totalling 1100 beds and 33,530 annual stays, 56% of them for emergency units inpatients. Mean age was 68 years, 54% were women, mean Charlson score was 2.6 and 44% of the patients took at least three drugs. Main causes of hospitalization were infectious (29%) and neurological (17%) diseases. Mean length of stay was 9.2 days. The medical team was composed by a median value of 4,5 [2,75–6,25] senior full-time equivalents, 86% were internists. Each department except one received residents, two third of them were from general medicine.ConclusionThis study highlights a high organizational variability among internal medicine departments and patients, and sets internal medicine as a specialty with a great capacity to achieve an integrative/comprehensive management of patients and to offer a comprehensive basis for physicians in training.     

Confidence of academic general internists and family physicians to teach ambulatory procedures

OBJECTIVE: To evaluate and compare the readiness of academic general internal medicine physicians and academic family medicine physicians to perform and teach 13 common ambulatory procedures. DESIGN: Mailed survey. SETTING: Internal medicine and family medicine residency training programs associated with 35 medical schools in 9 eastern states. PARTICIPANTS: Convenience sample of full-time teaching faculty. MEASUREMENTS AND MAIN RESULTS: A total of 331 general internists and 271 family physicians returned completed questionnaires, with response rates of 57% and 65%, respectively. Academic generalists ranked most of the ambulatory procedures as important for primary care physicians to perform; however, they infrequently performed or taught many of the procedures. Overall, compared with family physicians, general internists performed and taught fewer procedures, received less training, and were less confident in their ability to teach these procedures. Physicians’ confidence to teach a procedure was strongly associated with training to perform the procedure and performing or precepting a procedure at least 10 times per year. CONCLUSIONS: Many academic general internists do not perform or precept common adult ambulatory procedures. To ensure that residents have the opportunity to learn routine ambulatory procedures, training programs may need to recruit qualified faculty, train current faculty, or arrange for academic specialists or community physicians to teach these skills. Presented in part at the 1996 and 1998 meetings of the Society of General Internal Medicine and at the 1998 meetings of the Midwest Society of General Internal Medicine. This work was supported in part by grant 2D28PE54004 from the Bureau of Health Professions, Health Resources and Services Administration, to the Faculty, Development Program for General Internal Medicine, University of North Carolina at Chapel Hill, and by Grant 52285 from the Summa Health System, Akron, Ohio.     

Evidence-based medicine training in internal medicine residency programs

To characterize evidence-based medicine (EBM) curricula in internal medicine residency programs, a written survey was mailed to 417 program directors of U.S. internal medicine residency programs. For programs offering a freestanding (dedicated curricular time) EBM curriculum, the survey inquired about its objectives, format, curricular time, attendance, faculty development, resources, and evaluation. All directors responded to questions regarding integrating EBM teaching into established educational venues. Of 417 program directors, 269 (65%) responded. Of these 269 programs, 99 (37%) offered a freestanding EBM curriculum. Among these, the most common objectives were performing critical appraisal (78%), searching for evidence (53%), posing a focused question (44%), and applying the evidence in decision making (35%). Although 97% of the programs provided medline, only 33% provided Best Evidence or the Cochrane Library. Evaluation was performed in 37% of the freestanding curricula. Considering all respondents, most programs reported efforts to integrate EBM teaching into established venues, including attending rounds (84%), resident report (82%), continuity clinic (76%), bedside rounds (68%), and emergency department (35%). However, only 51% to 64% of the programs provided on-site electronic information and 31% to 45% provided site-specific faculty development. One third of the training programs reported offering freestanding EBM curricula, which commonly targeted important EBM skills, utilized the residents’ experiences, and employed an interactive format. Less than one half of the curricula however, included curriculum evaluation, and many failed to provide important medical information sources. Most programs reported efforts to integrate EBM teaching, but many of these attempts lacked important structural elements.     

Evidence-based medicine and the practicing clinician

OBJECTIVE: To assess the attitudes of practicing general internists toward evidence-based medicine (EBM-defined as the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions) and their perceived barriers to its use. DESIGN: Cross-sectional, self-administered mail questionnaire conducted between June and October 1997. SETTING: Canada. PARTICIPANTS: Questionnaires were sent to all 521 physician members of the Canadian Society of Internal Medicine with Canadian mailing addresses; 296 (60%) of 495 eligible physicians responded. Exclusion of two incomplete surveys resulted in a final sample size of 294. MAIN RESULTS: Mean age of respondents was 46 years, 80% were male, and 52% worked in large urban medical centers. Participants reported using EBM in their clinical practice always (33, 11%), often (173, 59%), sometimes (80, 27%), or rarely/never (8, 3%). There were no significant differences in demographics, training, or practice types or locales on univariate or multivariate analyses between those who reported using EBM often or always and those who did not. Both groups reported high usage of traditional (non-EBM) information sources: clinical experience (93%), review articles (73%), the opinion of colleagues (61%), and textbooks (45%). Only a minority used EBM-related information sources such as primary research studies (45%), clinical practice guidelines (27%), or Cochrane Collaboration Reviews (5%) on a regular basis. Barriers to the use of EBM cited by respondents included lack of relevant evidence (26%), newness of the concept (25%), impracticality for use in day-to-day practice (14%), and negative impact on traditional medical skills and "the art of medicine" (11%). Less than half of respondents were confident in basic skills of EBM such as conducting a literature search (46%) or evaluating the methodology of published studies (34%). However, respondents demonstrated a high level of interest in further education about these tasks. CONCLUSIONS: The likelihood that physicians will incorporate EBM into their practice cannot be predicted by any demographic or practice-related factors. Even those physicians who are most enthusiastic about EBM rely more on traditional information sources than EBM-related sources. The most important barriers to increased use of EBM by practicing clinicians appear to be lack of knowledge and familiarity with the basic skills, rather than skepticism about the concept.     

Why should addiction medicine be an attractive field for young physicians?

Aims The clinical practice and science of addiction are increasingly active fields, which are attracting professionals from diverse disciplines such as psychology and neurobiology. Our scientific knowledge of the pathophysiology of addiction is rapidly growing, along with the variety of effective treatments available to clinicians. Yet, we believe that the medical specialties of addiction medicine/psychiatry are not attracting the interest and enthusiasm of young physicians. What can be done? Methods We offer the opinions of two experience addiction psychiatrists. Results In the US, there has been a decline in the number of psychiatrists seeking training or board certification in addiction psychiatry; about one‐third of graduates with such training are not practicing in an addiction psychiatry setting. There is widespread neglect of addiction medicine/psychiatry among the medical profession, academia and national health authorities. This neglect is unfortunate, given the enormous societal costs of addiction (3–5% of the gross domestic product in some developed countries), the substantial unmet need for addiction treatment, and the highly favourable benefit to cost yield (at least 7:1) from treatment. Conclusions We believe that addiction medicine/psychiatry can be made more attractive for young physicians. Helpful steps include widening acceptance as a medical specialty or subspecialty, reducing the social stigma against people with substance use disorders, expanding insurance coverage and increasing the low rates of reimbursement for physicians. These steps would be easier to take with broader societal (and political) recognition of substance use disorders as a major cause of premature death, morbidity and economic burden.