emergency medicine within all four years of medical school

Integrating Emergency Medicine Into All 4 Years of Medical School

Nicholas Kman, MD & Chad D. Viscusi, MDCORD Academic Assembly 2015

No Disclosures

Objectives Explain importance of early, consistent EM education

for all medical students. Discuss opportunities to engage & have impact

throughout the 4 year curriculum. Highlight learning communities, the “How to be a

doctor course”, and EMIG. Evaluate factors that influence a student’s choice of

specialty as related to above.

EM Education for All! Every student must have basic knowledge of evaluation &

management of acutely ill or injured patient… But WHY? Charge of Josiah Macy Report 1994. Mandate / Reaffirmation of LCME standards, 2004. EPA 10: AAMC Core EPA’s for Entering Residency, 2014

Recognize patient requiring urgent or emergent care and initiate evaluation and management .

Requirement of graduation. Necessary for independent practice. Societal expectation for any physician…

…okay, maybe not of the psychiatrist/pathologist/radiologist? ;)

EM Education for All? Medical emergencies may arise anywhere, anytime EM education just as ubiquitous? Academic Departments & GME outpacing UGME:

Formal integration of EM curriculum slow. Clinical exposure often not until 4th year. Not all medical schools require EM rotations.

18% in 1992, 35% in 2005, 52% as of 2014 State of the clerkship survey. (www.ncbi.nlm.nih.gov/pubmed/24552529)

BLS/ACLS often delayed until MS3 or MS4 and many schools have no life support course requirement.

Funds Flow

http://www.ncbi.nlm.nih.gov/pubmed/24552529

The Why?: Russi & Hamilton, Acad EM, October 2005

“A Case for Emergency Medicine in the Undergraduate Medical School Curriculum.” – The reasons / obstacle? 1. EM education during all years not clearly endorsed. 2. Faculty resistance in already crowded curriculum. 3. Low EM representation on curriculum committees. 4. Lack of organized national core EM curriculum…

CDEM Clerkship Primer, published 3rd, 4th, PEM curricula 5. Already overcrowded ED clinical environment. 6. Lack of creativity & innovation in med student ed.

The Data: NRMP 2015 data…:

3rd Most popular specialty for US medical grads. 1821 Positions Offered 99.6% filled. UAZ=3rd most popular with 12 matches (1 EM/IM) OSU=3rd most popular specialty behind IM and Peds;

increasing match rates with 26 matches this year (including one EM/IM).

EM Faculty Assets:

Expertise with acute care of undifferentiated patient. Skill in efficient & high yield info gathering. Capacity quick decisions & critical judgement. Ability to initiate care for any patient/problem. Broad understanding of many medical specialties

informs student career advising. Deep understanding of health care systems.

EM Faculty Charges: Become Indispensable:

Fully integrate into all aspects of COM!! Participate in curriculum committees, LCME visit & audit.

Showcase our skills and knowledge: Teach, Mentor, Precept, Design & Improve

Develop and implement acute care curricula. US Anatomy, SIM case correlations

Very helpful to have emergency physician as Dean!!

“With great power comes great responsibility.” Voltaire

So How Do I Get Involved?

Opportunities - Pre-Med Factors have + influence on decision to study

medicine, including physicians, health-related work experience, and a health professional advisor.

Impressions students form in this ‘‘premed’’ period can influence careers in medicine.

Opportunities - Pre-Med Colleges and universities have student

organizations, clubs, or interest groups for ‘‘careers in medicine.’’

“Dine with docs”, Shadowing COM Admissions Committee Undergrad Emergency Medical Services

course…

Undergraduate course- overview of care provided by EMS Required Text:

Brennan, J.A., Krohmer, J.R. (Editors), Principles of EMS Systems, 3rd Edition, American College of Emergency Physicians, Sadbury, MA: Jones and Bartlett Publishers, 2006.

Required Journal Articles on EBM EMS Performance Measures Required Incident Command Online Courses – U.S.D.H.S. 3 days/week (M,W,F) over course of one semester. Has been very well received and will be strong asset for DEM.

http://emergencymed.arizona.edu/students/elective/emd-350-emergency-medical-services

Development of a Novel Course to Integrate EMS Fellow, EM Resident, and Undergraduate Education in EMS Systems Organization and Deployment

Joshua B. Gaither, Hans R. Bradshaw, Jennifer J. Smith, Kristina Waters, Daniel W. Spaite

Arizona Emergency Medicine Research Center, College of Medicine, University of Arizona, Tucson, Arizona

Background

Needs

Objectives

Methods

Results

Benefits to Students

Benefits to Faculty

Benefits to EMS Fellows

EMS fellowship faculty are frequently asked to perform not only educational outreach for EMS providers but also education for medical students, residents, & fellows. In small faculty groups this can place significant work loads on each faculty member & make it difficult to get volunteers to provide ongoing EMS lectures.

Several students expressed a need for formal EMS systems education.

Undergraduate Public Health

PremedEmergency Management

Graduate Students Medical Students

EM ResidentsEMS Fellows.

Use a cooperative teaching approach to optimize faculty time and improve the quality and quantity of EMS educational opportunities available to Undergraduates, Medical Students, Residents, and EMS Fellows at the University of Arizona

Develop a course that would provide students with an in-depth knowledge of EMS systems, their operations and oversight that required no prerequisite medical education, making it broadly applicable to undergraduate, graduate, and post-doctoral students.

Emergency Medical Services “EMD 350”

3-credit, 45 hour courseSummer session and Spring semester

Course topics included:• History of EMS• Provider and system roles• State and regional EMS systems, trauma systems• EMS Medical oversight, operations and financing• Communications, documentation & information systems• Special populations, public health• Disaster response• Occupational health• Medical-legal

Subspecialty EMS physicians and local EMS agency leaders enhance the educational experience by delivering lectures on:• Tactical EMS• Weapons of Mass Destruction• Community paramedicine• And more ….

• One of only two courses taught by College of Medicine(COM) faculty that are open to undergraduates

• Opportunity to have one-on-one interactions with multiple COM faculty members

• Opportunity to meet local EMS system leaders• Provide insight into possible career

opportunities in EMS and EMS systems management.

• This summer course provides the fellow with a foundation in EMS systems prior to field time.

• Fulfills a large number of the non-clinical ACGME educational requirements.

• Opportunity to gain valuable teaching experience

• Allows the EMS fellow to meet and interact with multiple local EMS system leaders and innovative thinkers.

• Increase the number of participants in each lecture

• Opportunity to create alternative funding sources

• Decrease in the overall number of lectures and lecture time each faculty member devotes to overall education.

Opportunities - Preclinical

Orientation Lectures PBL/CBI Radiology EKG Course BLS / ACLS APLS / PALS Mentoring

Physical Exam How to be MD Simulation Procedures EMIG Shadowing Comm Service Research

Opportunities - Clinical

Core Experiences: MS3 Elective MS4 Clerkship EM/CC Clerkship Acting Internship PEDS-EM A.I. Boot camps/Capstones

Opportunities - Clinical

• Electives (VSAS lists 353 Electives under EM):• Toxicology• Sports Medicine• Wilderness Medicine• Global Health• EMS / Disaster• EM Ultrasound• EM Research• Others…

Opportunities - Longitudinal Learning Communities Clubs & EM Interest Groups Longitudinal CPR Elective Ultrasound Correlations Procedural Thread Simulation Cases EM Research Advising & Mentoring Honors Longitudinal Electives

Opportunities - Longitudinal Learning Communities Clubs & EM Interest Groups Longitudinal CPR Elective Ultrasound Correlations Simulation Cases EM Research Advising & Mentoring Honors Longitudinal Electives

Bahner, D P (07/02/2013). "Integrated medical school ultrasound: development of an ultrasound vertical curriculum". Critical ultrasound journal (2036-3176), 5 (1), p. 6.

Longitudinal CPR Instructor Elective & REACT

Longitudinal CPR Certification & Community Instruction Course Requirements (MS1-2, MS3-4):

Become CPR Instructor Certified- AHA or ARC course Teach CPR to the community – AHA or CCO – 15,20hrs Attend or Podcast All Didactic Sessions Resuscitative skills lab sessions – Attend 2,2 sessions Course evaluation: Pass/Fail

REACT (Resuscitation Education and CPR Training) Group

http://emergencymed.arizona.edu/students/CPR-elective

Learning Communities:

Background:

LCME Standard MS-31-A: Medical schools must document that they provide a supportive learning environment, promote the well being of medical students and facilitate their adjustment to the physical and emotional demands of medical education.

L.C.’s aim to provide students with academic & social support and have emerged to help meet the need for curricular reform and evolving understanding of how medical students learn.

Definition: “…an intentionally developed group for students and/or faculty designed to enhance medical school experience and maximize learning.”

Foster higher level of “engagement and intellectual interaction with peers, faculty, curriculum…”

2006 Survey of all U.S. & Canadian medical schools (N=124) to document purpose, structure, function, benefits, challenges of those communities (N=18).

Variable purposes: Academic, social support/activities, curriculum delivery, advising or any combination…

Academic Medicine V84(11)November 2009

…


Common Primary Goals: Fostering communication among students & faculty Promoting caring, trust, and teamwork Helping establish academic & social support networks

Structural Characteristics: Mandatory, students from all years, linked to faculty mentor

Curricular Purposes: Professionalism, Leadership, Service, Humanities, Cultural

Almost all: Career Advising, Personal Counselling


“An intentionally created group of students and/or faculty actively engaged in learning from each other.”

Survey of 151 AAMC schools, Oct 2011-March 2012 126/151 responders, 66 schools c LC’s, 29 considering Targeted problems:

Fragmented teaching relationships, and curricula, social isolation due to long hours, and lack of support.

Proposed solutions / opportunity to transform Med-Ed: Longitudinal faculty/student relationships in small-group

settings, focus on role-modeling & continuity.

Academic Medicine V89(6)June 2014

Educational Focus: Mentoring – 89% Advising – 71% Curricular – 60% Social – 52% Community Service – 34% 91% chose >1 category… Doctoring course: 49%


Logistics: Budget: $10k-$1.4m ($400k) Faculty#: 17mean, 10median Funded Time: ~20% FTE Staff: 2mean @ 50% FTE Designated Space: 48% White Coat Ceremony: 67%

Greatest Benefits: Mentoring, Role-modeling Inc. sense of connection Student-faculty interaction Longitudinal relationships Active, small group learning Community service Personal, professional growth Personalized education


Greatest Challenges: Funding Time Space Curricular implementation Keeping students involved Coordinating social activities Faculty development Faculty retention

Two page questionnaire MS2-4 in 1999 & 2003 assessed connections, participation, benefits, concerns about LCs.

Conclusions: LCs contribute to more positive perception of learning environ LCs associated c increased interaction among students LCs seem to increase student leadership development LCs seem to increase student engagement in the community

Qualitative comments highlight difficulty of vertical integration and peer mentoring with MS3s & MS4s…

Academic Medicine V89(6)June 2014Academic Medicine V82(5)May 2007

Survey: 150 LC faculty mentors, Oct 2011-May 2012 (86%RR) Johns Hopkins, UofAZ-Tucson, UTSW, UVA, Vanderbilt Effect of LCs on faculty members’ job satisfaction. Serving in a medical school learning community may be an

effective tool to promote job satisfaction. Involvement increases faculty engagement with the academic

community and may improve faculty clinical skills. Formalized financial support, protected teaching time, and

faculty development for learning community mentors increase faculty engagement benefits.

Conclusions: Academic clinical faculty members reported serving as a mentor in an LC was a strong source of job satisfaction. LC may be a tool for retaining clinical faculty members in academic careers.

Do LC’s accomplish their stated purposes?

Not yet much outcome data for students: Improved retention? Improved academic achievement? Improved mental health? Effect on empathy, the hidden curriculum? Areas of future research? Best Practices? Evaluating impact of LC’s based on the intended purpose. Impact of method of student selection on effectiveness. Integration of students from other health professions?

Learning Communities: The AZ Experience 4-year integrated program created in 2006,

“to teach clinical and professional skills and to provide longitudinal clinical mentoring” to all COM students.

Purpose: Early instruction, from the very first day, in the development of

fundamental clinical skills including communication, taking a medical history, and the physical examination of patients

Early introduction to what it means to be a medical professional and the importance of professionalism in the practice of medicine

Provision of an ongoing support system that emphasizes both peer support and the support of dedicated medical school faculty

The AZ Experience: Structure Class divided 4 societies: Agave, Acacia, Cholla, Manzanita. Each society had 5 mentors, each mentor has 5-6 students. 4/20 Current mentors are Emergency Medicine Faculty Groups meet weekly 1p-5p years 1&2 and quarterly 3&4. Responsible for administering the Doctor & Patient course. Required Texts:

Bates’ Guide to Physical Exam & History Taking Henderson- The Patient History: An EBM Approach

The Online Learning Portfolio. Formative & Summative Feedback

History Final, P.E. Final, Year 2 OSCE, Year 3 OSCE

The AZ Experience: Activities White Coat Ceremony: Mentors coat their students Healthcare bedside experience on COM Day #1! Intensive foundational History taking & Physical Exam

instruction and directly observed practice. Observed/mentored bedside H&P’s: Inpatient & E.D. Standardized Patient Clinical Labs

The AZ Experience: Activities Clinical Thinking / Medical Decision Making Sessions Oral Presentation Practice & Peer Review Written H&P instruction & feedback Longitudinal mentoring & professional guidance Faculty development & curriculum revision.

Learning Communities: The OSU Experience In 2007, OSU created LCs, as “An intentional

community of professionals dedicated to mentorship, professionalism education, enculturation, social support and career guidance.”

The Learning Community Leader serves as initial advisor Students in a group have regular meetings from year 1-4

(monthly in years 1 & 2, and quarterly in year 3 & 4) Once student begins the more formal process of

residency/career selection, they tend to find a specialty advisor

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Learning Communities: University of Iowa (Takacs)Medical Student Grand Rounds

Student led Grand RoundsAll M1s and M2s from one of 4 Learning

CommunitiesAll available M3s and M4s, regardless of

CommunityInterdisciplinary option

PharmacyNursingDentistry

Learning Communities: The audience experience?

Does Longitudinal Physician Faculty Exposure Influence Career Choice in Medical Students?

The OSU Experience:

Giano LA, Kman NE, Harzman AE, Verbeck N, Nagel R, Post D

Students and Career Choice: What Matters? Unknown whether longitudinal attending physician

exposure influences career choice At OSU, students are exposed to attending faculty

during small groups on a weekly basis in a physician development course called Clinical Assessment and Problem Solving (CAPS)

Faculty from various specialties (Family Medicine, Internal Medicine, Pediatrics, PM&R, OB/GYN, Emergency Medicine, Pathology) participated as small group facilitators.

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Longitudinal Teaching and Career Choice They are also exposed to a faculty member

longitudinally across 4 years in the small group setting of Learning Communities

CAPS and LC group leaders are assigned randomly, without respect to students’ career goals

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Clinical Assessment and Problem Solving (CAPS) CAPS is a longitudinal course that teaches

the basics of becoming a physician This includes history taking, physical

examination, ethics, professionalism, and the basics of health care delivery

Majority of the course is taught in small groups of 12 students led by a physician facilitator

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Hypothesis The specialty of the longitudinal small group

faculty instructor impacts future career choice

OSU Experience: Methods We began with all students in the graduating classes

of 2012, 2013, and 2014 Compared facilitator and student specialty choice

(overall student sample size =680) Chi square analysis was performed for each

facilitator’s specialty to examine student specialty match with faculty

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OSU Experience: Methods Students and instructors also analyzed based on

person-oriented versus technique-oriented specialties Person-oriented specialties included family practice,

internal medicine, obstetrics and gynecology, pediatrics, physical medicine and rehabilitation, and psychiatry

Technique-oriented specialties included anesthesiology, dermatology, emergency medicine, otolaryngology, pathology, radiology, and surgery

58Borges, NJ., et al. “Influences on specialty choice for students entering person-oriented and technique-oriented specialties.” Medical Teacher, v. 31 issue 12, 2009, p. 1086-8.

OSU Experience: Results There was no significant association between the

specialty of the CAPS instructor and career choice of students

Additional analysis included co-facilitators from different specialties each CAPS year, this also showed non-significant results

Med 2’s matched with person-oriented facilitators pursued a similar field more often (51.6%) than those matched with technique-oriented facilitators (36.2%).

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Comparison Between Student Career Choice and Med1 CAPS Instructors’ Specialties

%

Comparison Between Student Career Choice and Med2 CAPS Instructors’ Specialties

Comparison Between Student Career Choice and Learning Community Instructors’ Specialties

Comparison Between Student Career Choice and CAPS Instructors’ Specialties for Technique vs. Person-oriented and Primary vs. Specialty Care

OSU Experience: Results There was a positive association in the Learning

Communities among students with a facilitator from Plastic Surgery 7.7% (2/26) of students who had a plastic surgeon LC leader

matched into the specialty, versus 0.9% (4/448) whose LC leader was not a plastic surgeon

No association between person vs. technique oriented specialties

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OSU Experience: Conclusion Faculty specialty in longitudinal physician

development courses does not influence career choice in medical students in most cases

One exceptions to this pattern was seen in our institution with students more likely to match with their plastic surgeon LC leader

Final Pearls EM should have a place across all 4 years of medical

school (LCME would agree). Our bright and talented faculty & residents must make

this a reality. Learning Communities, “How to be a Doctor” course, and

EMIG offer great opportunities to start. Get your project started with an SAEM/EMIG grant!

Additional Reading… DeBehnke, D J (11/1998). "Undergraduate curriculum. SAEM

Undergraduate Education Committee, Society for Academic Emergency Medicine". Academic emergency medicine (1069-6563), 5 (11), p. 1110.

Tews, M C (10/2011). "Integrating emergency medicine principles and experience throughout the medical school curriculum: why and how". Academic emergency medicine (1069-6563), 18 (10), p. 1072.

Russi, C S (10/2005). "A case for emergency medicine in the undergraduate medical school curriculum". Academic emergency medicine (1069-6563), 12 (10), p. 994.

SAEM Undergraduate Education Committee for 2004-2005, S. A. (10/2005). "Impact of the Liaison Committee on Medical Education requirements for emergency medicine education at U.S. schools of medicine". Academic emergency medicine (1069-6563),12 (10), p. 1003.

Bahner, D P (07/02/2013). "Integrated medical school ultrasound: development of an ultrasound vertical curriculum". Critical ultrasound journal (2036-3176), 5 (1), p. 6.

Additional Reading Kman NE, Bernard AW, Martin D, Bahner D, Gorgas D, Nagel R, and Khandelwal S. 2011.

“Advanced topics in emergency medicine: curriculum development and initial evaluation.” Western Journal of Emergency Medicine, v. 12 issue 4, 2011, p. 543-50.

Dubosh NM. Kman NE, Bahner D. "Ultrasound interest group: a novel method of expanding ultrasound education in medical school." Critical Ultrasound Journal 3.3 (2011): 131-134.

References1. Compton, MT; Frank, E; Elon, L; Carrera, J. “Changes in U.S. medical students' specialty

interests over the course of medical school.” Journal of General Internal Medicine, v. 23 issue 7, 2008, p. 1095-100.

2. Dorsey, ER; Jarjoura, D; Rutecki, GW. “Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by US Medical Students.” Journal of the American Medical Association, September 3, 2003- v. 290, No. 9, p. 1173-1178.

3. Dorsey, ER; Jarjoura, D; Rutecki, GW. “The Influence of Controllable Lifestyle and Sex on the Specialty Choices of Graduating U.S. Medical Students, 1996-2003.” Academic Medicine, v. 80, no. 9/ September 2005, p. 791-796.

4. Hauer, KE., et al. “Factors associated with medical students' career choices regarding internal medicine.” JAMA : Journal of the American Medical Association, v. 300 issue 10, 2008, p. 1154-64.

5. Borges, NJ., et al. “Influences on specialty choice for students entering person-oriented and technique-oriented specialties.” Medical Teacher, v. 31 issue 12, 2009, p. 1086-8.

6. Kman NE, Bernard AW, Khandelwal S, Nagel R, Martin D. A Tiered Mentorship Program Improves Number of Students with an Identified Mentor. Teaching and Learning in Medicine, 25:4, 2013.

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emergency medicine within all four years of medical school

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