The emergency medicine rotation: a unique experience for medical students

IFEM model curriculum: emergency medicine learning outcomes for undergraduate medical education

BACKGROUND

The International Federation for Emergency Medicine (IFEM) published its model curriculum for medical student education in emergency medicine in 2009. Because of the evolving principles of emergency medicine and medical education, driven by societal, professional, and educational developments, there was a need for an update on IFEM recommendations. The main objective of the update process was creating Intended Learning Outcomes (ILOs) and providing tier-based recommendations.

METHOD

A consensus methodology combining nominal group and modified Delphi methods was used. The nominal group had 15 members representing eight countries in six regions. The process began with a review of the 2009 curriculum by IFEM Core Curriculum and Education Committee (CCEC) members, followed by a three-phase update process involving survey creation [The final survey document included 55 items in 4 sections, namely, participant & context information (16 items), intended learning outcomes (6 items), principles unique to emergency medicine (20 items), and content unique to emergency medicine (13 items)], participant selection from IFEM member countries and survey implementation, and data analysis to create the recommendations.

RESULTS

Out of 112 invitees (CCEC members and IFEM member country nominees), 57 (50.9%) participants from 27 countries participated. Eighteen (31.6%) participants were from LMICs, while 39 (68.4%) were from HICs. Forty-four (77.2%) participants have been involved with medical students' emergency medicine training for more than five years in their careers, and 56 (98.2%) have been involved with medical students' training in the last five years. Thirty-five (61.4%) participants have completed a form of training in medical education. The exercise resulted in the formulation of tiered ILO recommendations. Tier 1 ILOs are recommended for all medical schools, Tier 2 ILOs are recommended for medical schools based on perceived local healthcare system needs and/or adequate resources, and Tier 3 ILOs should be considered for medical schools based on perceived local healthcare system needs and/or adequate resources.

CONCLUSION

The updated IFEM ILO recommendations are designed to be applicable across diverse educational and healthcare settings. These recommendations aim to provide a clear framework for medical schools to prepare graduates with essential emergency care capabilities immediately after completing medical school. The successful distribution and implementation of these recommendations hinge on support from faculty and administrators, ensuring that future healthcare professionals are well-prepared for emergency medical care.

Second- and third-year medical students' clinical encounters in the emergency department

Background

Experiential learning theory suggests that direct clinical experiences facilitate learning. Previous literature has focused primarily on the experiences of fourth-year medical students. As more students gain early clinical exposure, it is important to understand the types of patients seen by junior students.

Objectives

This study aims to categorize the clinical experiences of early (M2 and M3) students in the emergency department (ED).

Methods

A retrospective review of the electronic health record of patients seen by M2s and M3s on a 2-week emergency medicine rotation at a single urban academic ED in the Midwest was performed. Data elements extracted included total number of patients seen, Emergency Severity Index (ESI), disposition, and chief complaint. Students were not mandated to see any particular patients.

Results

Medical students (248) saw 2994 total patients from 2018 to 2022. The median number of patients seen by each student was 12.0 (range 1-32). Pediatric patients made up 6.5% (n = 194) of total patients. Encounters were primarily ESI 2 or 3, which accounted for 89.4% of all patients (n = 2676). The most encountered complaints were abdominal pain, chest pain, and dyspnea, making up 15.6% (n = 467), 8.7% (n = 260), and 5.5% (n = 165), respectively, of total cases. Obstetrics/gynecology, hematologic, and environmental disorders were the least frequently encountered domains. No students saw all Clerkship Directors in Emergency Medicine (CDEM)-recommended complaints.

Conclusions

There is significant variability in the ED encounters of M2s and M3s, with wide ranges of patient volume and presentations. This study provides some evidence that early students may not be meeting CDEM recommendations.

Characteristics of University Hospitals Implementing the Postgraduate Clinical Training "Tasukigake Method" and Their Correlation with Program Popularity: A Cross-Sectional Study

PURPOSE

In 2004, the postgraduate clinical training system in Japan was radically revised by introducing a super-rotation matching system. Although postgraduate clinical training became a mandatory 2 years of training, the program and operation were left to each facility's discretion, leading to training-program popularity differences. The Japanese Tasukigake method provides clinical training in which "hospitals where junior residents work" and "external hospitals/clinics that provide clinical training" conduct clinical training alternately on a 1-year basis. The study aimed to identify the characteristics of university hospitals that implement the Tasukigake method to help educators and medical institutions create more attractive and effective programs.

METHODS

All 81 university main hospitals were included in this cross-sectional study. The information regarding Tasukigake method implementation was collected from the facilities' websites. The training program's matching rate (popularity) was calculated from the Japan Residency Matching Program's interim report data (academic 2020). We used multiple linear regression analysis to evaluate the association between Tasukigake method implementation, program popularity, and university hospital characteristics.

RESULTS

The Tasukigake method was implemented by 55 (67.9%) university hospitals, significantly more by public university hospitals (44/55, 80%) than by private (11/55, 20%) (P < 0.01) and by hospitals without branches (38/55, 69.1%) than with branches (17/55, 30.9%) (P < 0.001). The maximum hiring capacity of junior residents (P = 0.015) and number of branches (P < 0.001) were negatively correlated, and the population of the hospital's city (P = 0.003) and salary/month (P = 0.011) were positively correlated with the Tasukigake method implementation. Multiple linear regression analysis results showed no significant association between the matching rate (popularity) and Tasukigake method implementation.

CONCLUSION

The results show no association between Tasukigake method and program popularity; also, highly specialized university hospitals in cities with fewer branch hospitals were more likely to implement the Tasukigake method.

Understanding junior doctors' experiences of teaching on the acute take: a qualitative study

BACKGROUND

New medical graduates are significantly unprepared to manage acutely unwell patients due to limited first-hand clinical exposure in the undergraduate curriculum. Supporting undergraduate learning in the acute setting can be challenging for junior doctors when balancing teaching and clinical responsibilities. Our aim was to explore junior doctors' first-hand experiences of supporting undergraduate education in the acute admissions environment(take).

METHODS

Fourteen junior doctors in one teaching hospital in South West England took part in semi-structured focus groups (4-6 participants in each) which were audio-recorded, transcribed, and thematically analysed.

RESULTS

Junior doctors described their educational role as comprising: teaching, demonstrating, coaching, and supervising. They perceived the acute take as a highly variable, unpredictable setting that offered a broad scope for learning. Tensions between doctors' clinical and educational roles were described, influenced by internal and external factors. Clinical work was prioritised over teaching and participants lacked confidence in supervisory and clinical skills. Doctors felt pressured to meet students' expectations and lacked understanding of their educational needs. Senior colleagues were highly influential in establishing an educational culture and were often a source of pressure to deliver timely clinical care. Organisations were perceived not to value teaching due to the lack of provision of dedicated teaching time and prioritisation of limited resources towards patient care. Participants managed tensions by attempting to formally separate roles, demoting students to passive observers, and they sought greater continuity in placements to better understand students' abilities and expectations.

CONCLUSIONS

Educational opportunities for undergraduate students on the acute take are varied and highly valuable. This study provides insight into the provision of workplace education and its challenges from junior doctors' perspectives. We highlight areas for improvement of relevance to educational providers.

Differences in clinical knowledge levels between residents in two post-graduate rotation programmes in Japan

BACKGROUND

In Japan, between 2010 and 2020, there were two post-graduate training curricula for post-graduate medical education, as follows: comprehensive rotation programmes (CRPs), which require rotation in at least seven clinical departments; and limited rotation programmes (LRPs), which require rotation in fewer clinical departments. The curriculum that should be used for standardized Japanese post-graduate training has long been debated. Multiple studies show that post-graduate trainees who trained with CRPs were more satisfied and confident and gained more clinical experience than those who trained with LRPs. However, a comparison of objective measurements of the clinical knowledge of Japanese post-graduate trainees has not been reported. The aim of this study is to objectively measure and compare the clinical knowledge of trainees in CRPs and LRPs using a component of the Professional and Linguistic Assessment Board test (PLAB test).

METHODS

A nationwide cross-sectional study was conducted in February and March 2020. Post-graduate trainees who graduated from medical school were voluntarily recruited from general hospitals in Japan. To objectively measure the trainees' basic clinical knowledge, the PLAB test was adapted from the UK. The cut-off point was set at 63%, as recommended by the UK General Medical Council. A statistical analysis was conducted to determine whether post-graduate programme differences contributed to the trainees' test scores.

RESULTS

Twenty-two facilities volunteered to participate after recruitment, and 97 trainees from 19 facilities participated in the study. Thirty-one participants (32%) were in a CRP, and 66 participants (68%) were in an LRP. According to multiple logistic regression, the adjusted odds ratio of CRP trainees being in the high-scoring group was 5.16 (95% CI: 1.28-20.73, p<0.05). Mean differences in the scores in paediatrics, mental health and neurology were statistically higher among CRP trainees than LRP trainees.

CONCLUSION

Post-graduate trainees who were in a CRP had better basic clinical competence knowledge (PLAB test) scores and performed better when tested in a wider range of subspecialties. Not only exam performance but also clinical performance and the longitudinal trend of trainees' competency in post-graduate medical training should be evaluated in future studies.

Emergency medicine clerkship director experience adapting emergency remote learning during the onset of COVID-19 pandemic

OBJECTIVES

The recent outbreak of the COVID-19 altered the traditional paradigm of clinical medical education. While individual clerkships have shared their curricular adaptations via social and academic networking media, there is currently no organizational standard in establishing a nonclinical, emergency medicine (EM) virtual rotation (VR). The primary objective of this study was to describe EM clerkship directors' (CDs) perspectives on their experience adapting an EM VR curriculum during the onset of the COVID-19 pandemic.

METHODS

A 21-item survey with quantitative and qualitative questions was disseminated between June and August 2020 to EM CDs via the Clerkship Director of Emergency Medicine Listserv to describe their experience and perspectives in adapting a VR during spring 2020.

RESULTS

We analyzed 59 of 77 EM clerkship survey responses. Among respondents, 52% adapted a VR while 47.5% did not. Of those who adapted a VR, 71% of CDs had 2 weeks or less to develop the new curriculum, with 84% reporting usual or increased clinical load during that time. Clerkships significantly diversified their asynchronous educational content and utilized several instructional models to substitute the loss of clinical experience. Reflecting on the experience, 71% of CDs did not feel comfortable writing a standardized letter of evaluation for students based on the VR, with the majority citing inability to evaluate students' competencies in a clinical context.

CONCLUSION

A crisis such as COVID-19 necessitates change in all facets of medical education. While EM educators demonstrated the ability to create emergency remote learning with limited time, this was not equivalent to the formal development of preplanned VR experiences. Future faculty development and curriculum innovation are required to fully transition an in-person immersive experience to a noninferior virtual experience.

Converting to Connect: A Rapid RE-AIM Evaluation of the Digital Conversion of a Clerkship Curriculum in the Age of COVID-19

BACKGROUND

With the advent of the 2019 coronavirus pandemic, a decision was made to remove medical students from clinical rotations for their own safety. This forced students on a core emergency medicine (EM) rotation at McMaster University to immediately cease all in-person activities. An urgent need for a virtual curriculum emerged.

METHODS

A virtual curriculum consisting of asynchronous case-based learning on Slack, ask-me-anything webinars, and online e-modules was created to fill the need. We describe a program evaluation using the RE-AIM framework and a social networking analysis of participants.

RESULTS

Medical students (n = 23) and 11 facilitators (five residents, six faculty members) participated in this pilot study. Faculty members sent a mean (±SD) of 115 (±117) messages (n = 6), and mean (±SD) message counts for students and residents were 49.96 (±25; n = 23) and 39 (±38; n = 5), respectively. A total of 62,237 words were written by the participants, with a mean of 1,831 per person. Each message consisted of a mean (±SD) of 25 words (±29). Students rapidly acquitted themselves to digital technology. Using the RE-AIM framework we highlight the feasibility of a virtual curriculum, discuss demands on faculty time, and reflect on strategies to engage learners.

CONCLUSIONS

The use of asynchronous digital curricula creates opportunities for faculty-resident interaction and engagement. We report the successful deployment of a viable model for undergraduate EM training for senior medical students in the COVID-19 era of physical distancing.

Out of hours, out of sight? Uncovering the education potential of general practice urgent care for UK undergraduates

There is a need to increase undergraduate primary care exposure and subsequently enhance primary care recruitment. This study aimed to establish the current use and education potential of the primary care out of hours (OOH) learning environment. This was a mix methods study. A questionnaire was sent to UK primary care heads of teaching nationally to explore the current use of GP OOHs in the undergraduate curriculum and focus groups evaluated final year medical students' experience of an OOH placement. There was a 100% response rate from primary care heads of teaching. Despite 86% being in favour of integrating OOH placements within the undergraduate curriculum, only 28% of medical schools currently offer primary care OOH placements. 36 out of 240 students volunteered for a clinical OOH session. Focus group data from 6 of these students revealed that the placements provided unique learning opportunities and allowed students to appreciate the organisational structure of the National Health Service (NHS). However, barriers included logistical difficulties with the OOH providers and inadequate supervision. It appears that we are overlooking a unique educational opportunity for medical undergraduates. With increasing demands for GP exposure within the undergraduate curriculum, GP OOH is a useful resource for UK medical schools.

What difference can a year make? Findings from a survey exploring student, alumni and supervisor experiences of an intercalated degree in emergency care

BACKGROUND

One third of UK medical students undertake an intercalated degree, typically in traditional academic disciplines. It is less usual for students to undertake intercalated degrees that are directly aligned to a clinical speciality with longitudinal placements. This cross sectional survey aims to explore the self-reported experiences of students, alumni and supervisors associated with a clinically oriented intercalated degree in emergency care featuring a longitudinal placement in a hospital emergency department over a 9-month academic year. Themes for exploration include student clinical and academic development, effect on career choice, supervisor experience and the effect on host institutions.

METHODS

Current students, previous alumni, and clinical placement supervisors associated with a single intercalated degree programme in urgent and emergency care since 2005 were identified from records and using social media. Separate online surveys were then developed and distributed to current students/ previous alumni and consultant physician supervisors, between May and August 2016. Results are presented using basic descriptive statistics and selected free text comments.

RESULTS

Responses were obtained from 37 out of 46 contactable students, and 14 out of 24 supervisors (80 and 63%, respectively). Students self-reported increased confidence in across a range of clinical and procedural competencies. Supervisors rated student competence in clinical, inter-professional and academic writing skills to be commensurate with, or in many cases exceeding, the level expected of a final year medical student. Supervisors reported a range of benefits to their own professional and personal development from supervising students, which included improved teaching and mentoring skills, providing intellectual challenge, and helping with the completion of audits and service improvement projects.

CONCLUSIONS

Students report the acquisition of a range of clinical, academic, and inter-professional skills following their intercalated BSc year. A positive experience was reported by supervisors, extending to host institutions. Students reported feeling more enthusiastic about emergency medicine careers on completion. However, as students embarking on this degree naturally bring pre-existing interest in the area, it is not possible to attribute causation to these associations. Further investigation is also required to determine the longer term effect of clinically oriented intercalated degrees on career choice.

Emergency Medicine Resident Self-assessment of Clinical Teaching Compared to Student Evaluation Using a Previously Validated Rubric

PURPOSE

The quality of clinical teaching in the emergency department from the students' perspective has not been previously described in the literature. Our goals were to assess senior residents' teaching ability from the resident/teacher and student/learner viewpoints for any correlation, and to explore any gender association. The secondary goal was to evaluate the possible impact of gender on the resident/student dyad, an interaction that has previously been studied only in the faculty/student pairing.

METHODS

After approval by an institutional review board, a 1-year, grant-funded, single-site, prospective study was implemented at a regional medical campus that sponsors a 4-year dually approved emergency medicine residency. The residency hosts both medical school students (MSs) and physician's assistant students (PAs). Each student and senior resident working concurrently completed a previously validated ER Scale, which measured residents' teaching performance in 4 categories: Didactic, Clinical, Approachable, and Helpful. Students evaluated residents' teaching, while residents self-assessed their performance. The participants' demographic characteristics gathered included prior knowledge of or exposure to clinical teaching models. Gender was self-reported by participants. The analysis accounted for multiple observations by comparing participants' mean scores.

FINDINGS

Ninety-nine subjects were enrolled; none withdrew consent. Thirty-seven residents (11 women) and 62 students (39 women) from 25 MSs and 6 PA schools were enrolled, completing 517 teaching assessments. Students evaluated residents more favorably in all ER Scale categories than did residents on self-assessments (P < 0.0001). This difference was significant in all subgroup comparisons (types of school versus postgraduate years [PGYs]). Residents' evaluations by type of student (MS vs PA) did not show a significant difference. PGY 3 residents assessed themselves higher in all categories than did PGY 4 residents, with Approachability reaching significance (P = 0.0105). Male residents self-assessed their teaching consistently higher than did female residents, significantly so on Clinical (P = 0.0300). Students' evaluations of the residents' teaching skills by residents' gender did not reveal gender differences.

IMPLICATIONS

MS and PA students evaluated teaching by EM senior residents statistically significantly higher than did EM residents on self-evaluation when using the ER Scale. Students did not evaluate residents' teaching with any difference by gender, although male residents routinely self-assessed their teaching abilities more positively than did female residents. These findings suggest that, if residency programs utilize resident self-evaluation for programmatic evaluation, the gender of the resident may impact self-scoring. This cohort may inform future study of resident teaching in the emergency department, such as the design of future resident-as-teacher curricula.

The role of emergency medicine clerkship e-Portfolio to monitor the learning experience of students in different settings: a prospective cohort study

Background

Although emergency departments provide acute care learning opportunities for medical students, student exposure to recommended curriculum presentations and procedures are limited. In this perspective, clinical environments providing learning opportunities for students should be monitored as part of an ongoing quality improvement process. This study aims to analyze student exposures and their involvement levels in two different hospitals (Tawam and Al Ain) so as to improve the teaching and learning activities.

Methods

This is a prospective study on all 76 final year medical students’ electronic logbooks (e-Portfolio) of the academic year 2016/2017.

Results

Students recorded 5087 chief complaints and 3721 procedures. The average patient and procedure exposure in a shift per student in Al Ain Hospital compared with Tawam Hospital were 7.2 vs 6.4 and 5.8 vs 4.3, respectively. The highest full involvement with presentations was seen in the pediatric unit (67.1%, P < 0.0001). Urgent care shifts demonstrated the highest area of “full involvement” with procedures for our students (73.2%, P < 0.0001). Students’ highest involvement with presentations and procedures were found during the night shifts (P < 0.0001, 66.5 and 75.1%, respectively).

Conclusions

The electronic portfolio has proven to be a very useful tool in defining the learning activities of final year medical students during their emergency medicine clerkship and in comparing activities in two different clinical settings. Data collected and analyzed using this e-Portfolio has the potential to help medical educators and curriculum designers improve emergency medicine teaching and learning activities.

Do senior medical students meet recommended emergency medicine curricula requirements?

BACKGROUND

Emergency departments (EDs) offer a variety of learning opportunities for undergraduate medical students. It is however, difficult to evaluate whether they are receiving recommended training during their emergency medicine (EM) clerkship without identifying their clinical activities. We aimed to evaluate the clinical exposure of the final year medical students at our College during their EM clerkship.

METHODS

This is a retrospective analysis of prospectively collected student logbooks. 75 students rotated in a 4-week EM clerkship during 2015-2016. The students rotated in EDs of two hospitals. Each ED treats more than 120,000 cases annually. The students completed 12 eight-hours shifts. Presentations and procedures seen were compared with EM curriculum recommendations.

RESULTS

Five thousand one hundred twenty-two patient presentations and 3246 procedures were recorded in the logbooks, an average (SD) of 68.3 (17.6) patients and 46.1 (14.0) procedures. None of the students encountered all ten recommended presentations. Two students (2.6%) logged all nine procedure categories of the EM curriculum.

CONCLUSION

Recommended presentations and procedures of the EM clerkship were not fully encountered by all our students. Different settings vary in the availability and type of patients and procedures. Each clinical clerkship should tailor their teaching methods based on the available learning opportunities.

Evaluating validity of current criteria for judgment passing ER rotation among internee medical students

Background

Passing the emergency medicine internship is an essential process for all graduates of medical schools. The main purpose of this study was to evaluate validity of current criteria for judgment passing ER rotation among internee medical students.

Methods

In this cross-sectional study, a total of 200 students in the emergency departments (ED) of the teaching hospitals at Tehran University of Medical Sciences (TUMS) were included. The data were gathered using by a valid self-assessment questionnaire including demographic information and 12-items about the students' level of confidence with the skills and procedures under study. Statistical analyses were done using SPSS (version 22).

Results

200 medical students participated in this study. A Univariate analysis showed a significant correlation between successfuly completions of training in emergency medicine (passing emergency medicine in past rotations) with some items in self-assessment questionnaire same as knowledge of interns in managing emergency situations (p = 0.009). The Spearman test demonstrated a significant correlation between the duration of emergency training (number of months which interns spent on the emergency training) with the some items in self-assessment questionnaire same as importance of emergency medicine training (p = 0.019).

Conclusions

According to association between successfully completions of training in emergency medicine and self-assessment questionnaire, it seems current criteria for judgment passing emergency medicine rotation is valid as well as we recommended using self-assessment for evaluating validity of such testes.

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Previous studies have shown that the results of clinical tests in emergency medicine and other clinical education courses do not correlate accurately with a medical student's degree of confidence in performing tasks and their readiness for future career.

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Validity and authenticity of clinical test in emergency medicine and other clinical education course must be evaluated to ensure that these examinations predict whether the students who pass have greater skills and confidence when compared to the ones who fail the rotation.

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Self-assessment is an effective tool for evaluating validity of clinical tests.

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.

Medical students' perceptions of an emergency medicine clerkship: an analysis of self-assessment surveys

BACKGROUND

No studies have been performed that evaluate the perceptions of medical students completing an emergency medicine (EM) clerkship. Given the variability of exposure to EM in medical schools nationwide, assessment of the student rotation may inform the structure and content of new and existing clerkships, particularly in relation to student's acquisition of the core competencies.

OBJECTIVES

To investigate whether undergraduate medical students rotating through an EM clerkship improved their understanding and abilities in core content areas and common procedural skills; to evaluate whether improvement was affected by rotation length.

METHODS

All students participating in an EM clerkship over a 12-month period were asked to complete an anonymous voluntary pre- and post-rotation survey. Confidence with patient assessment, diagnosis, and management plans; trauma and medical resuscitations; formal and informal presentations; basic procedure skills and understanding of the modern practice of EM were self assessed using a Likert scale. Group mean scores on each question on the pre- and post-clerkship surveys were calculated and compared. The mean scores on each survey item, both pre- and post-clerkship, were compared between 2- and 4-week clerkship rotation groups.

RESULTS

Two hundred thirty-nine students participated in the rotation during the 12 months of the study. One hundred sixty-one (161), or 67.4%, completed the pre-rotation survey, and 96 (40.2%) completed the post-rotation survey. Overall, students showed significant mean gains in confidence with initial patient assessment, diagnosis, and management plans (p < 0.01, 0.02, <0.01) and with basic procedure skills (p < 0.01 for all). Students completing a 2-week rotation did not differ significantly from f4week rotators in confidence levels, except in the area of formal presentation skills (p = 0.01), where the 4-week students demonstrated a statistically significant advantage. The 2-week clerkship participants were significantly less confident in all procedures except EKG interpretation, splinting, and venipuncture (p = 0.28, 0.22, 0.05). Regardless of rotation length, students generally felt they had sufficient exposure to patients and opportunities for hands-on learning and practice, and overwhelmingly would recommend the EM clerkship to a fellow student, regardless of their chosen specialty.

CONCLUSIONS

Medical students show significant gains in confidence with acute care knowledge, disease management, and procedure skills after completion of an EM clerkship. Although a 4-week clerkship may be preferable to expose students to the widest variety of patients and procedures, all students can benefit and improve in core competencies after an EM undergraduate experience.

Third-year medical student rotations in emergency medicine: a survey of current practices

OBJECTIVES

Exposure to emergency medicine (EM) is a crucial aspect of medical student education, yet one that is historically absent from third-year medical student training. There are limited data describing the existing third-year rotations. The goal of this study is to identify the content and structure of current EM rotations specific to third-year students.

METHODS

An institutional review board-approved survey of clerkship characteristics was designed by consensus opinion of clerkship directors (CDs). The survey was distributed to 32 CDs at institutions with known EM clerkships involving third-year students.

RESULTS

Twenty-three (72%) CDs responded to the survey. Sixty-five percent have rotations designed specifically for third-year students, of which 33% are required clerkships. Twenty-seven percent of rotations have prerequisite rotations; 37% of rotations include shifts in the pediatric ED. Clinical time averages four 8-hour shifts per week for 4 weeks; all rotations include weekly didactic time specific to third-year students. A wide variety of textbooks are used; some programs employ simulation labs. Two-thirds of the rotations have a required write-up or presentation; 53% include a final exam. Student evaluations are written and verbal. Most rotations receive more support from the EM departments than from the medical schools for physical space, administrative needs, and faculty time. Among those surveyed, students from institutions requiring a third-year EM rotation have a higher rate of application to EM residencies.

CONCLUSIONS

There is variability in the content and structure of existing third-year EM rotations, as well as in financial and administrative needs and support. These data can help to inform CDs and departments that are starting or modifying EM third-year rotations, as well as contribute to the development of curricula for such rotations.

Emergency medicine in the medical school curriculum

Emergency medicine (EM) is a dynamic specialty that continues to define itself as a fertile training ground for medical students. Throughout the years, a number of U.S. medical schools have incorporated topics germane to EM training (basic cardiac life support, principles of wound care, splinting, basic procedural skills training, etc.) into the medical school curriculum. By virtue of their broad-based training and the unique patient care environment that they practice in, EM specialists can serve a multitude of educational roles in the medical school. Whether serving as a problem-based learning facilitator, collaborating with basic scientists, or teaching medical history-taking and physical examination skills in the emergency department (ED), EM faculty can effectively teach future physicians in training. Although opportunities for teaching will vary by institution, often all it takes to get involved is asking. Teaching can take place in the ED, classroom, or simulation center, both in the preclinical and in the clinical curriculum. EM faculty may be well suited to help teach procedural skills to students as they enter their clinical clerkships. A formal rotation in EM can also assist the medical school in achieving their institutional objectives or in identifying ways to satisfy the Liaison Committee on Medical Education's objectives. Patients presenting to the ED span the entire spectrum: young and old, sick and not sick. It is this variety of cases that makes the ED a truly valuable setting for educating students.

The effect of emergency department observational experience on medical student interest in emergency medicine

BACKGROUND

In many different health care educational models, shadowing, or observational experience, is accepted as integral to introducing students to the specifics of medical specialties.

STUDY OBJECTIVES

We investigated whether emergency department (ED) observational experiences (EDOs) affect medical students' (MSs') interest in emergency medicine (EM). Additionally, we examined how the subjective quality of clinical exposures influences this interest and the decision to recommend EDOs to other students.

METHODS

This is a survey of MSs at a Level 1 tertiary care university hospital during a 2-year period. The study focused on assessing perception of ED exposure, post-EDO change in EM interest, and decision to recommend EDOs to others.

RESULTS

The majority of MSs had a change in EM interest post-EDO and recommended EDOs. Both variables correlated to ED exposure ratings.

CONCLUSIONS

The EDO significantly influenced MS interest in EM by providing exposure to various aspects of the ED.

Multicenter trial of the clinical activities tool to document the comparability of clinical experiences in obstetrics-gynecology clerkships

PURPOSE

To assess the implementation of the Clinical Activities Tool (CAT) for facilitating Liaison Committee on Medical Education-required documentation of the comparability of obstetrics-gynecology (ob/gyn) clinical experiences and midclerkship feedback at multiple sites during one academic year.

METHOD

Ob/gyn clerkship students at six U.S. medical schools were given CATs to guide and document clinical experiences from June 2006 to June 2007. Students used a paper CAT at five institutions and an electronic version at one. CATs listed procedures, skills, and topics recommended by the Association of Professors of Gynecology and Obstetrics and included a midclerkship feedback section. Resident/faculty signatures documented completion of items for paper CATs. Electronic CAT item completion was self-documented by students. Students completed a questionnaire on CAT use.

RESULTS

At the six schools, 876 medical students rotated on ob/gyn clerkships; 808 (92%) submitted CATs. Mean item completion rate was 72%. Five of six schools achieved >/=70% completion rates. Midclerkship feedback signature rates ranged from 0% to 97.8% with four of six schools reporting >/=65% feedback. Comparability of clinical experiences and midclerkship feedback was successfully documented across sites for each institution (number of sites: range = 1-9; median = 5). Questionnaires on CAT use were submitted by 231 students (26%). Students using paper CATs reported that doing so clarified course objectives (93%), provided clerkship guidance/structure (93%), and facilitated interaction with faculty/residents (76%/74%). Students rated the electronic CAT significantly less favorably.

CONCLUSIONS

CAT implementation at multiple institutions for documentation of student clinical experience comparability and midclerkship feedback was successful. Students evaluated the paper CAT positively.

Clerkship directors in emergency medicine: statement of purpose

The Academy of Clerkship Directors in Emergency Medicine (CDEM) provides a forum for the collaborative exchange of ideas among emergency medicine (EM) medical student educators, a platform for the advancement of education, research, and faculty development, and establishes for the first time a national voice for undergraduate medical education within our specialty. CDEM plans to take a leading role in providing medical student educators with additional educational resources and opportunities for faculty development and networking. CDEM will work to foster the professional growth and development of undergraduate medical educators within our specialty. The advancement of undergraduate education within our specialty and beyond will come primarily from the support, hard work, and dedication of the educators. To accomplish our goals, at the departmental, medical school, and national level, we must come together to further promote our specialty across the spectrum of undergraduate medical education. The first step has already been taken with the formation of the Academy of CDEM.

Emergency medicine subinternship: does a standard clinical experience improve performance outcomes?

BACKGROUND

The emergency medicine (EM) subinternship provides a varied experience for senior medical students depending on gender, specialty choice, and interest. A didactic curriculum can be standardized, but the clinical component is difficult to control. Students can be directed to see patients with specific chief complaints.

OBJECTIVES

To assess whether a clinical requirement of 10 predetermined cases improves general knowledge as measured on an objective exam.

METHODS

This was a prospective, nonrandomized, case-controlled study at a public teaching hospital. Students were assigned to the control group (CG) or test group (TG) by alternating block rotations over 6 months. The CG saw emergency department (ED) patients according to interest and faculty direction. The TG was also required to identify ten specific chief complaints. Patient encounters were recorded in computerized logs. A 10-question pretest assessed preexisting knowledge of each chief complaint, and a 40-question final exam tested general EM knowledge. Descriptive statistics measured demographic data. Groups were compared by Fisher's exact test. Difference in means testing was performed to see if pre- to posttest differences varied by group. Multivariate analysis controlled for gender and specialty choice.

RESULTS

Eighteen CG students saw a mean of 57 patients, and 24 TG students saw a mean of 54 patients; 1 CG student (6%) and 7 TG students (31.8%) saw all 10 required cases (Fisher's exact test p = 0.044). Difference in means testing demonstrated a greater relative change in performance (13.4% points) by the TG relative to the CG on a general knowledge exam, compared with their performance on a brief pretest (p = 0.014). The authors performed multivariate regression controlling for pretest score, gender, and EM specialty choice, and neither gender nor intended EM specialty choice was a contributing factor to the improved performance. A greater relative change in performance (7% points) in the TG exam score was found when compared to the CG (p = 0.020).

CONCLUSIONS

Students who participated in the usual didactic curriculum and were required to see ED patients with representative chief complaints performed better on a general EM exam than those who employed common methods of choosing patients.

Undergraduate training in the care of the acutely ill patient: a literature review

OBJECTIVE

To characterise the problem of teaching acute care skills to undergraduates and to look for potential solutions.

DESIGN

Systematic literature review including Medline, EMBASE, CINAHL. Eligible studies described education and training issues focusing on caring for acutely ill patients. Articles were excluded if they did not address either educational or clinical aspects of acute care and resuscitation.

MEASUREMENT AND RESULTS

We identified and reviewed 374 articles focusing on training or clinical aspects of caring for the acutely ill patient. Undergraduates and junior physicians lack knowledge, confidence and competence in all aspects of acute care, including the basic task of recognition and management of the acutely ill patient. There is wide variability both between and within countries regarding the amount of teaching in critical care offered to undergraduate medical students. Many centres are starting to use an integrated approach to acute care teaching, with early exposure to basic life support and clinical skills, coupled with later exposure to more complex acute care topics. Clinical attachments remain a popular method for training in acute care. Acute care courses are increasingly being used to standardise delivery of practical skills and patient management training.

CONCLUSION

The training of healthcare staff in the care of acutely ill patients is suboptimal, adding to patient risk. Improvements in training should start at undergraduate level for maximal effect, should be integrated with postgraduate education, and are likely to enhance current efforts to improve patient safety in acute care.

Documenting comparability of clinical experience on the obstetrics and gynecology clerkship

OBJECTIVE

This study was undertaken to develop a process that provides Liaison Committee on Medical Education (LCME)-required documentation of obstetric/gynecology (OB/GYN) clinical experience comparability and mid-clerkship feedback.

STUDY DESIGN

Institutional review board approval was obtained. OB/GYN clerkship students at the University of North Carolina (UNCSOM) from June 2004 through June 2005 were given Clinical Activities Tools (CATs) to guide clinical work. CAT books listed Association of Professors of Gynecology and Obstetrics-recommended topics/procedures/skills and had a section for mid-clerkship feedback. Residents/faculty signed CAT sections to document student completion of topics/procedures/skills/feedback. CAT tool data were analyzed with univariate, chi2, and analysis of variance statistics.

RESULTS

CATs were submitted by 81% (134/165) of students; 71% of CAT clinical activities had teacher signatures. CAT comparability was successfully documented for all topics/procedures/skills and for mid-clerkship feedback across sites and across rotation blocks. CATs provided active learning/communication opportunities and data used for curriculum revision.

CONCLUSION

CATs facilitated successful documentation of clinical experience comparability and mid-clerkship feedback. The process is feasible and likely will be helpful to other institutions.

Demographic and clinical characteristics of patients admitted to medical departments

INTRODUCTION

The significant changes, which have affected departments of medicine over the last two decades, have been much editorialized. Surprisingly few data have been published that document these changes. We describe the demographic and clinical characteristics of patients admitted to one hospital's departments of internal medicine.

METHODS

During a 3 months prospective study, 1039 patients (46% of all 2277 new admissions to the departments of medicine, consisting of +/- 175 beds) were randomized for inclusion. Information was extracted from the medical records regarding demography; functional capacity; clinical data and outcome.

RESULTS

The mean age of the patients was 72 +/- 16 years (mean +/- SD); 51% were male, 56% were married, and 83% lived at home. Although 293 patients (28%) were defined as dependent, the majority lived at home (170, 58%). Cognition was normal in only 74%. The four most common disease categories leading to admission were infections (383 patients, 37%), cardiovascular disorders (372, 36%), respiratory conditions (284, 27%) and genito-urinary problems (90, 9%). Overall, 98 persons died (9%). Independent risk factors for death were: mechanical ventilation; a 'do not resuscitate' order; a high APACHE-II score; a low serum albumin level; higher age; and not being married (P < 0.01).

CONCLUSIONS

Geriatric patients occupy a central position in our medical wards. These data are relevant for allocation of special resources for departments with high proportions of geriatric patients; for the design of employment conditions that ascertains continuing job satisfaction; as well as for the planning of teaching opportunities for residents and students.

An educator's guide to teaching emergency medicine to medical students

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

Emergency psychiatry training for third-year medical students as reported by directors of medical student education in psychiatry

BACKGROUND

Physicians can expect to confront a variety of psychiatric emergencies during their careers. However, medical schools are not required to teach emergency psychiatry and little is known about the content of existing instruction.

PURPOSES

We conducted this survey to better understand the emergency psychiatry experiences provided to 3rd-year medical students.

METHODS

Directors of medical student education in psychiatry at U.S. medical schools were mailed a 1-page questionnaire about their school's instruction in emergency psychiatry.

RESULTS

We received 74 responses from the 122 U.S. medical schools (61%). All but 4 reported emergency psychiatry instruction. The number of hours and type of settings students were on-call varied greatly from school to school, as did the scope of faculty supervision.

CONCLUSIONS

Most schools provide emergency psychiatry instruction, but methods vary among institutions. Given its importance, medical schools should work to provide uniformity in the way emergency psychiatry is taught.