The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–20, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2014.12.063

Education IMPLEMENTING A THIRD-YEAR EMERGENCY MEDICINE MEDICAL STUDENT CURRICULUM Matthew C. Tews, DO, MS,* Collette Marie Ditz Wyte, MD,† Marion Coltman, MD,† Kathy Hiller, MD,‡ Julianna Jung, MD,§ Leslie C. Oyama, MD,k Karen Jubanyik, MD,{ Sorabh Khandelwal, MD,# William Goldenberg, MD,** David A. Wald, DO,†† Leslie S. Zun, MD,‡‡ Shreni Zinzuwadia, MD,§§ Kiran Pandit, MD, MPH,kk Charlene An, MD, MSC,{{ and Douglas S. Ander, MD## *Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, †Department of Emergency Medicine, Oakland University, William Beaumont School of Medicine, Royal Oak, Michigan, ‡Department of Emergency Medicine, University of Arizona Health Network, Tucson, Arizona, §Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, kUCSD Emergency Medicine, University of California, San Diego, San Diego, California, {Department of Emergency Medicine, Yale-New Haven Hospital, New Haven, Connecticut, #Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, Ohio, **Department of Emergency Medicine, Naval Medical Center, San Diego, California, ††Department of Emergency Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania, ‡‡Department of Emergency Medicine, Mount Sinai Hospital, Chicago Medical School, Chicago, Illinois, §§Department of Emergency Medicine, New Jersey Medical School-University Hospital, Newark, New Jersey, kkDepartment of Emergency Medicine, Columbia University, New York, New York, {{Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York, and ##Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia Reprint Address: Matthew C. Tews, DO, MS, Department of Emergency Medicine, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226

, Abstract—Background: Emergency medicine (EM) is commonly introduced in the fourth year of medical school because of a perceived need to have more experienced students in the complex and dynamic environment of the emergency department. However, there is no evidence supporting the optimal time or duration for an EM rotation, and a number of institutions offer third-year rotations. Objective: A recently published syllabus provides areas of knowledge, skills, and attitudes that third-year EM rotation directors can use to develop curricula. This article expands on that syllabus by providing a comprehensive curricular guide for the third-year medical student rotation with a focus on implementation. Discussion: Included are consensus-derived learning objectives, discussion of educational methods, considerations for implementation, and information on feedback and evaluation as proposed by the Clerkship Directors in Emergency Medicine Third-Year Curriculum Work Group. External validation results, derived from a survey of third-year rotation directors, are provided in the form of a content validity index for

each content area. Conclusions: This consensus-derived curricular guide can be used by faculty who are developing or revising a third-year EM medical student rotation and provide guidance for implementing this curriculum at their institution. Ó 2015 Elsevier Inc. , Keywords—third-year; curriculum; medical student; emergency medicine

INTRODUCTION Emergency medicine (EM) offers medical students a variety of clinical experiences that are directly applicable to their future careers, regardless of specialty choice (1,2). Students completing an EM rotation encounter acutely ill and injured patients with complaint-based presentations. They learn the evaluation and management of the

RECEIVED: 13 May 2014; FINAL SUBMISSION RECEIVED: 5 November 2014; ACCEPTED: 22 December 2014 1

2

M. C. Tews et al.

undifferentiated patient in addition to learning how to handle common and life-threatening medical problems. A fourth-year rotation has traditionally been the most common EM experience for medical students (3). A recent survey has shown that EM is also incorporated into the third year at many institutions (4). When situated in the third year, the goals of an EM rotation are fundamentally different than for more senior students. While a fourth-year EM experience focuses on creating diagnostic and management plans for patients, the thirdyear rotation provides exposure to EM principles and practice, teaching the approach to the undifferentiated patient and basic emergency management skills (5,6). The literature provides a number of resources relating to the fourth year, but there are few resources with a focus on the third-year experience (3,6–12). For all of these reasons, EM educators would benefit from a uniform curricular approach to the education of students in the third year. To address this need, this article provides a comprehensive curricular guide that expands on a previously published syllabus of content to include consensus-derived learning objectives, discussion of educational methods, considerations for implementation, and information regarding feedback and evaluation (5). It provides the rotation director with the core content and resources needed to implement or revise a third-year rotation. External validation results, derived from a survey of third-year rotation directors across the country, are provided in the form of a content validity index (CVI) for each of the content areas (13). This curriculum was developed using the six-step Kern model for curriculum development and is presented in this fashion (14). DISCUSSION Step 1: Problem Identification and General Needs Assessment There is currently a significant emphasis on competencybased education, as evidenced by initiatives like the American Council on Graduate Medical Education’s next accreditation system or ‘‘Milestones’’ and the American Association of Medical Colleges’ document on Entrustable Professional Activities (EPAs) (15,16). EPAs are observable and measurable descriptors of what all medical school graduates should be expected to perform on day 1 of residency without direct supervision. Among these, medical school graduates are expected to be able to recognize and initially manage patients requiring urgent or emergent care. This underscores the importance of EM competencies as core foundational skills for all medical students, and reinforces the role of EM in helping medical schools meet Liaison Committee on Medical Education (LCME) requirements (17,18).

Despite the recognition of emergency management as a core competency for all physicians, medical schools have variable integration of EM into their existing curricula (4,12). While there is no evidence supporting the optimal placement of EM in the medical school curriculum, many institutions offer EM during the fourth year of medical school because of a perceived need to have more experienced students in the complex and dynamic environment of the emergency department (ED). To address this need, a fourth-year EM medical student curriculum was published and recently updated to provide a consistent clinical experience for the senior medical student (6). However, a number of institutions offer third-year rotations either in place of or in addition to a fourth-year rotation. In a recent survey of EM clerkship directors in the United States, 28% have an elective third-year rotation and 14% have a required third-year EM experience at their institution (4). These experiences are variable with differences in the type and length of clinical experience, content taught, assessment methods and types of resources used (12). Due to this variability, as well as the growing prevalence of third-year EM rotations, the Clerkship Directors in Emergency Medicine (CDEM) Third Year Curriculum Work Group was formed in 2010 with the goal of promoting uniformity of the third-year EM experience and developing a curriculum that addresses the core knowledge, skills, and attitudes essential for third-year EM students. Step 2: Targeted Needs Assessment In 2011, the Work Group published a syllabus of content for a third-year EM rotation using the National Institute of Health model for consensus building (5). The publication was the result of a targeted needs assessment conducted by 17 EM rotation directors and experienced educators. The group compiled a broad list of content areas that was further refined via a series of online surveys, emphasizing the approach to the undifferentiated patient, the ability to differentiate patient acuity, the ability to perform simple procedures, and the basic management of critical life-threatening emergencies. The syllabus content was compiled into a ‘‘MustShould-Can’’ framework. In this model, ‘‘Must’’ indicates essential components to be provided by all institutions, regardless of rotation length. ‘‘Should’’ indicates highly desirable elements, and ‘‘Can’’ indicates elements that can be taught depending on the institution’s strengths and resources. This framework provides flexibility to EM educators within their individual institutions, while ensuring that critical ‘‘Must’’ elements are taught universally in the third year. Although this curriculum is recommended for a four-week clerkship, the ‘‘Must-

Third-Year EM Medical Student Curriculum

Should-Can’’ model allows for placement at any point during the third year, adaptation for the experienced versus the novice student, shorter rotations, inter-specialty or longitudinal EM experiences and multi-site rotations (19,20). The third-year syllabus was designed to be a distinct entity from the fourth-year medical student curriculum. After publication of the syllabus, the Work Group drafted learning objectives for all curricular content. Using the Delphi approach, Work Group consensus was obtained for the ‘‘Must’’ objectives through a series of online surveys. The ‘‘Should’’ and ‘‘Can’’ learning objectives were refined in the same way as the ‘‘Must’’ objectives. Given the wide variety of potential third-year curricula in existence, the Work Group sought input from thirdyear rotation directors external to the Work Group to assess the content validity of the curriculum. CDEM members were contacted via the CDEM list serve to identify third-year rotation directors willing to participate in an online survey. Thirteen rotation directors responded to the inquiry and each was sent an anonymous online survey. Of the 13 respondents, 11 completed the survey, representing a mix of student experience that include elective, selective, and mandatory rotations ranging from 2 to 6 weeks in length. Step 3: Goals and Objectives Curriculum goals for the third-year student. 1. To gain exposure to EM principles and practice. 2. To understand the signs and symptoms of the acutely ill or injured patient. 3. To become familiar with the initial evaluation of a broad variety of medical and surgical emergencies. 4. To develop a differential diagnosis based on lifethreatening causes of common chief complaints. 5. To develop an approach to the initial resuscitation and management of the undifferentiated patient. 6. To begin to develop the knowledge, skills, and attitudes necessary for the practice of EM. Learning objectives and core curriculum.Table 1 lists the ‘‘Must’’ learning objectives derived from the Work Group’s consensus recommendations, and outlines the core curriculum content, including potential educational and assessment methods, with correlations to the Accreditation Council for Graduate Medical Education competencies, the American Board of Emergency Medicine Milestones and the Entrustable Professional Activities for graduating medical students (15,16,21). Each content area is associated with a CVI based on the survey responses of the external third-year rotation di-

3

rectors. The learning objectives must be shared with all teaching faculty and residents to ensure consistent education and evaluation, and to meet LCME requirements for required clerkships (22). The ‘‘Should’’ (Appendix 1) and ‘‘Can’’ (Appendix 2) objectives are also included, but do not have an external validation component because they represent additional content areas that can be incorporated based on the resources of the department or institution. External validation of ‘‘Must’’ content and learning objectives. A CVI is a measurement of content relevance determined by a group of individuals knowledgeable in a content domain (13). To determine our curricular content validity, a group of 11 external third-year rotation directors reviewed the curricular content developed by our Work Group and provided perspective on the importance of each content area via a standardized electronic survey. The content validity index for each content area is listed in Table 1. The closer the CVI is to 1.0, the greater the extent of agreement, therefore, the higher the content validity (23). The overall CVI for all items is 0.90, indicating a high degree of validity for the curricular content. CVI calculations for the 16 content areas ranged from 0.64 to 1.00. Nine of 16 content areas had a CVI of 1.0 indicating the highest degree of content validity. The two areas with the lowest CVI, ‘‘Basic and Advanced Life Support Techniques’’ and ‘‘Documentation,’’ had only two individuals who disagreed, resulting in a value of 0.64, which still demonstrated a good degree of validity for these areas. Respondents to the survey were also asked if they would ‘‘agree, modify, or disagree’’ with each specific learning objective. Of the 41 ‘‘Must’’ learning objectives, >90% of external respondents agreed with 27 of them as written. There was little or no disagreement with most remaining objectives, with the majority choosing to ‘‘modify’’ the remaining ones. Suggestions for modifications were provided in some cases, but did not significantly alter the content of any learning objectives. The majority of disagreement surrounded the ‘‘Documentation’’ objectives. Respondents indicated that covering documentation in a shorter rotation is difficult or preferably reserved for the fourth year. Given the importance of documentation in EM, the Work Group retained documentation of the core chief complaints, as well as the procedural and medicolegal aspects, to provide students exposure to an important skill set that can be developed over time. Pediatrics. 1. Pediatrics is a core rotation in the third year of all United States (US) medical schools (22). The Council on Medical Student Education in Pediatrics has created a national curriculum that has been adopted by >90% of the Pediatric Clerkships in North America

4

Table 1. ‘‘Must’’ Third-Year Emergency Medicine Curriculum Content

Content

CVI

The Approach to the Undifferentiated Patient

1.00

Stabilization of the Acutely Ill Patient

0.82

Vital Signs

1.00

Basic and Advanced Life Support Techniques

0.64

Revised Learning Objectives

Assessment Methods†

ACGME Competencies, ABEM Milestones, ‡ and EPA§

References

L, IS, Podcast

C, G, SOE, MCQ, Sim, OSCE

PC-1,2,3,5,6 MK EPA-10

EMCP: Chapter 6: Undifferentiated and Differentiated Patients CDEM: Approach to the Undifferentiated Patient

L, IS

C, G, OSCE, Sim, SOE, MCQ

PC-1,2,3,4,5,6,10 MK EPA-10

CDEM: Stabilization of the Acutely Ill Patient; Approach to: Shock; Approach to: Gastrointestinal bleeding; Approach to: Trauma

L, IS

SOE, MCQ, EOS

PC-1,5,6,10 MK EPA-10

EMCP: Chapter 11: Developing Your Plan of Action CDEM: Approach to the Undifferentiated Patient

L, S, EL

C, G, Sim, MCQ

PC-1,4,5,6,10 MK EPA-10, 12

CDEM: Basic and Advanced Life Support Current BLS/ACLS/PALS guidelines

M. C. Tews et al.

1. Describe the approach to the ‘‘undifferentiated’’ patient. 2. Describe a ‘‘stable’’ vs. an ‘‘unstable’’ patient, identifying clinical signs and symptoms indicative of life-threatening illness.k 1. Describe the clinical approach to an unstable patient, including the assessment and monitoring of airway, breathing, and circulatory status.k 2. Describe the purpose of establishing an ‘‘intravenous, O2 and monitor’’ during initial assessment of the unstable patient.k 3. Describe the clinical approach to a patient in each category of shock (hypovolemic, cardiogenic, distributive, obstructive) and list the differential diagnoses 1. Interpret abnormal vital signs (heart rate, respiratory rate, blood pressure, temperature, and oxygen saturation) and identify the potential causesk 1. Describe the indications for using basic airway maneuvers, including head tilt, chin lift, and jaw thrust, and demonstrate their usek 2. Describe the indication for using airway adjuncts, including oral and nasopharyngeal airways, and demonstrate their use.k 3. Discuss the indications for bagvalve-mask ventilation and demonstrate the correct techniquek 4. Describe the approach to a patient in cardiac arrestk 5. Define and demonstrate highquality chest compressionsk 6. Demonstrate how to perform manual defibrillation

Educational Methods*

1.00

1. Perform a focused history and physical examination for a patient presenting with: a. Chest pain b. Abdominal paink c. Shortness of breathk d. Altered mental statusk

Chief Complaint Differential Diagnosis

1.00

Diagnostic Testing

1.00

Electrocardiogram (ECG)/Rhythm Recognition

0.82

1. List the common and lifethreatening causes of: a. Chest pain b. Abdominal paink c. Shortness of breathk d. Altered mental statusk Laboratory studies 1. Describe the indications and uses of common laboratory studies (e.g., complete blood count, basic metabolic panel, coagulation studies, liver function, lipase, cardiac enzymes and lactate), and what is normal vs. abnormal. Radiographic studies 1. Describe the indications and uses of a chest x-ray and abdominal series radiograph.k 2. Interpret a normal chest x-ray and abdominal series radiograph and identify potential life threatening findings.k Bedside testing 1. Interpret a normal 12-lead electrocardiogram (ECG) 1. Identify ventricular fibrillation (VF) and ventricular tachycardia (VT) on a rhythm strip and describe the initial treatment for the patient without pulses.k 2. Describe the initial management of shockable (VF and pulseless VT) vs. nonshockable (asystole and pulseless electrical activity) rhythms in cardiac arrest and list the potentially reversible causes (the Hs and Ts).k 3. Describe the causes, ECG criteria and management of an ST elevation myocardial infarction and interpret on an ECG.

L, IS, C, S, EL, SG

C, G, OSCE, Sim, SOE, SP, MCQ, EOS, BE, DO

PC-2 MK PBLI PROF-1,2 EPA-1

L, C, E, SG, S, IS

C, Sim, SOE, MCQ, EOS

PC-2, 3, 4 MK PBLI EPA-2

L, C, SG, Sim, IS

C, Sim, SOE, MCQ, EOS

PC-3 MK SBP-2,3 EPA-3

EMCP: Chapter 10: Diagnostic Testing in the Emergency Department CDEM: Diagnostic Testing

L, IS, S, EL

C, Sim, SOE, MCQ, EOS, BE

PC-3,4 MK EPA-10

CDEM: Diagnostic Testing; Approach to: Cardiac Arrest, Chest Pain, Diagnostic Testing Current BLS/ACLS/PALS guidelines

EMCP: Chapter 7: Performing a Complaint Directed H&P, and Chapter 8: Data Gathering Skills, and Chapter 11: Developing Your Plan of Action CDEM: The Approach to: Chest Pain, Abdominal Pain, Respiratory Distress and Altered Mental Status EMCP: Chapter 9: Developing a CaseSpecific Differential Diagnosis CDEM: The Approach to: Chest Pain, Abdominal Pain, Respiratory Distress and Altered Mental Status

Third-Year EM Medical Student Curriculum

Focused Chief Complaint History and Physical (H&P) Examination

Continued

5

Content

6

Table 1. Continued

CVI

Emergency Department (ED) Procedures

1.00

Acute Pain Control

0.82

Documentation

0.64

Disposition

0.82

Emergency Medicine within the US Health Care System

0.82

Revised Learning Objectives

Assessment Methods†

ACGME Competencies, ABEM Milestones, ‡ and EPA§

References

L, IS, C, S, EL

C, G, L, Sim, SOE, MCQ, EOS, BE

PC-9,13 MK EPA-12

EMCP: Chapter 20: Procedural Skills CDEM: Procedures

L, IS, C, SG

SOE, MCQ, EOS

PC-11 MK ICS EPA-12

CDEM: Acute Pain Control

L, C, S, SG

OSCE, P, RR, Sim, SP, MCQ, EOS

PC-2,6 MK ICS SBP-3 EPA-5

EMCP: Chapter 15: Documentation CDEM: Documentation of EM Encounters

L, IS, C, S, SG

SOE, MCQ, EOS

PC-7 MK ICS SBP-2

EMCP: Chapter 13: Disposition of the ED Patient and Chapter 14: Discharge Instructions

L, IS, SG

SOE, MCQ

MK PBLI SBP-2

EMCP: Chapters 1: Introduction to the Specialty of EM and Chapter 4: Unique Educational Aspects of Emergency Medicine and Chapter 5: Differences between the ED, the Office and the Inpatient Setting CDEM: Emergency Medicine in the US Healthcare System

M. C. Tews et al.

1. Describe the principles of basic wound care. 2. Demonstrate the correct technique for simple wound closure using simple interrupted sutures and staples.k 1. Describe strategies for managing pain using common oral and parenteral medications. 2. Describe the use of common local analgesics for wound repair 1. Document pertinent positives and negatives from a focused history and physical examination for a patient with: a. Chest pain b. Abdominal paink c. Shortness of breathk d. Altered mental statusk 2. Describe the pertinent information needed for basic emergency medicine procedural documentation. 3. Discuss the medicolegal aspects of documentation in the ED. 1. Identify the different types of disposition from the ED and factors that influence these decisions. 2. Describe the pertinent items to be included in discharge instructions. 1. Discuss the function of the ED as a ‘‘safety net’’ for patient care, including 24/7 care, 24/7 faculty coverage and the socioeconomic challenges surrounding the uninsured and underinsured in obtaining care in the ED 2. Discuss the importance of interdisciplinary care within the ED.

Educational Methods*

1.00

Communication

0.80

Motivation

1.00

1. Demonstrate professionalism during interactions with patients, families, ED staff, and consultants when caring for patients in the ED. 2. Demonstrate a sensitivity toward individual and cultural diversity within the ED. 3. Demonstrate professionalism on the rotation (e.g., appropriate dress, language, punctuality). 1. Demonstrate effective patientcentered communication and the ability to develop and maintain rapport with patients and their families. 2. Demonstrate the ability to communicate with a culturally diverse patient population. 3. Demonstrate respectful communication with consultants, nursing, and other staff in the ED. 1. Demonstrate willingness to see patients, perform procedures, and follow through on patient diagnostic and therapeutic interventions. 2. Demonstrate willingness to improve one’s own knowledge by engaging in self-directed learning during clinical shifts. 3. Demonstrate ability to navigate the literature to find evidencebased answers to clinical questions.

L, IS, R, C, S

C, G, OSCE, RR, SOE, SP, MCQ, EOS, BE

ICS PROF-1,2 SBP-1 EPA-9

EMCP: Chapter 23: Introduction to the Core Competencies CDEM: Professionalism

L, IS, R, C, S

C, G, OSCE, RR, SOE, SP, MCQ, EOS, BE

PBLI ICS-1,2 PROF-1, 2 SBP-1,2 EPA-9

EMCP: Chapter 17: Interacting with Consultants and Primary Care Physicians and EMCP: Chapter 23: Introduction to the Core Competencies CDEM: Communication

IS, R, C

C, G, L, RR, EOS

PC-6 MK PBLI EPA-7

EMCP: Chapter 22: How to Get the Most Out of Your Emergency Medicine Clerkship

7

ABEM = American Board of Emergency Medicine; ALS = advanced life support; BLS = basic life support; CDEM = CDEMcurriculum.org; CVI = Content Validity Index; ED = emergency department; EMCP = Emergency Medicine Clerkship Primer; EPA = Entrustable Professional Activities; PALS = pediatric advanced life support; SDOT = standardized direct observation assessment tool. * C = clinical ED setting; E = E-learning; IS = independent study/reading; L = lecture; R = reflection; S = simulation; SG = small group sessions. † C = checklist evaluation of live or recorded performance (e.g., SDOT, Mini-Clinical Evaluation Exercise); BE = bedside evaluations; DO = direct observation; EOS = end of shift evaluations; G = Global rating of live or recorded performance; L = procedure or case logs; MCQ = written examination; OSCE = objective structured clinical examination or standardized patients; P = portfolios; RR = record review; S = patient surveys; Sim = simulations and task trainers; SOE = standardized oral examination. ‡ ICS = interpersonal and communication skills; MK = medical knowledge; PBLI = practice-based learning and improvement; PC = patient care; PRO = professionalism; SBP = system-based practice; PC-1 = Emergency Stabilization; PC-2 = Performance of a Focused History and Physical; PC-3 = Diagnostic Studies; PC-4 = Diagnosis; PC-5 = Pharmacotherapy; PC-6 = Observation and Reassessment; PC-7 = Disposition; PC-8 = Multi-tasking; PC-9 = General Approach to Procedures; PC-10 = Airway Management; PC-11 = Anesthesia and Acute Pain Management; PC-12 = Goal Directed Focused Ultrasound; PC-13 = Wound Management; PC-14 = Vascular Access; MK = Medical Knowledge; PROF-1 = Professional Values; PROF-2 = Accountability; ICS-1 = Patient Centered Communication; ICS-2 = Team Management; PBLI = Practiced Based Performance Improvement; SBP-1 = Patient Safety; SBP-2 = Systems Based Management; SBP-3 = Technology. § EPA 1 = Gather a history and perform a physical examination; EPA 2 = Develop a prioritized differential diagnosis and select a working diagnosis following a patient encounter; EPA 3 = Recommend and interpret common diagnostic and screening tests; EPA 5 = Provide documentation of a clinical encounter in written or electronic format; EPA 7 = Form clinical questions and retrieve evidence to advance patient care; EPA 9 = Participate as a contributing and integrated member of an interprofessional team; EPA 10 = Recognize a patient requiring urgent or emergent care, initiate evaluation and treatment, and seek help; EPA 12 = Perform general procedures of a physician. k Objectives that cover both pediatric and adult resuscitation principles. ACGME = Accreditation Council for Graduate Medical Education; US = United States.

Third-Year EM Medical Student Curriculum

Professionalism

8

M. C. Tews et al.

(24). Recent work has further defined the content for a pediatric EM clerkship curriculum (25). Although the Work Group did not delineate pediatric-specific content, the objectives that are relevant for both adult and pediatric content are identified in Table 1. Step 4: Educational Strategies The core of any educational EM rotation is the clinical experience, however, the number and duration of shifts will vary, depending on the resources of the institution or department (4,12). During their clinical time, students should be exposed to the structure and function of the ED, learn the approach to patients with a variety of chief complaints, and begin to understand diagnosis and basic management principles for undifferentiated acutely ill or injured patients. This approach is fundamentally different from that used for the fourth-year student, who is expected to have experience with the basic approach to common complaints and is focused on honing higher-level diagnostic and management skills (6). The difference in experience and acumen between third and fourth-year students is a particular challenge for institutions that offer EM experiences for both groups. Clinical educators must take care to modify their expectations based on the student’s level of training, and adjust their teaching accordingly.

Faculty should identify developmentally appropriate learning opportunities for the third-year student in the ED, such as assisting or performing procedures, practicing history and physical examination skills, interpreting clinical data, seeing interesting patient presentations, or researching relevant clinical questions. Students should be directed to evaluate patients appropriate for their level of experience. Outside of the clinical arena, there are several educational methods that can be used to enhance student learning (26–32). While there are numerous effective educational methods, special consideration should be given to simulation as an educational method. Given the emphasis on practical skills and high-acuity presentations in EM curricula, simulation is particularly well suited to EM teaching. Simulation has been shown to be more effective than traditional instructional methods for improving procedural and teamwork performance, and it allows learners to practice ‘‘high stakes’’ skills in a risk-free environment (29,30). Each rotation director should select the most appropriate method to meet learning objectives based on their own clinical environment, institutional resources, and the needs of their students. Several possible strategies are listed in Table 2, along with positive and negative aspects of each, and are correlated to the content areas in Table 1.

Table 2. Educational Strategies Strategy E-Learning (27,28,33–38)

Small Group (39–41)

Simulation (29,30,42–44,45–49)

Reflection (31,32,50)

Lecture (21)

Independent study/reading (3)

Positive Aspect Electronic Interactive Learn at own pace Creates a virtual environment Requires little personnel time Team-based/problem-based learning Promotes discussion and clinical reasoning Higher level of application Promotes independent thought Replicates clinical environment Procedural/task training Standardized scenarios No risk of harm to patients Ideal clinical exposure for novice students Effective for teaching communication and teamwork Can be oral or written Leads to meaningful learning Formative or summative Helps promote self-awareness of students’ beliefs, values, and attitudes Efficient Large amount of information in short time Consistent coverage of objectives Large audience reached Can be done by podcast/electronic media asynchronously Student sets own pace No need for direct faculty involvement Can be delivered electronically

Negative Aspect Significant start up expense Large amount of time to create

Faculty development needed strong facilitator

Costly Time consuming Heavy personnel commitment Requires institutional resources

Takes time to become comfortable with Requires faculty time to read and interpret what student says Minimal interaction with teacher and student

Students need to be motivated May need direction on what to focus on

Third-Year EM Medical Student Curriculum

Step 5: Implementation New rotation directors may take on the daunting task of creating or redesigning an EM experience, often with minimal guidance or direction. In addition to building skills in teaching, curriculum development, and student assessment, rotation directors must be familiar with the practical aspects of overseeing a rotation (51–53). They must know and follow their institutional policies and national standards (22). Specific LCME requirements supported by this curriculum are listed in Appendix 3, which may serve as a resource for educators negotiating the initiation of a mandatory EM clerkship within their medical schools. There are several resources available to assist with implementation. One is the Guidebook for Clerkship Directors produced by The Alliance for Clinical Education, which is a comprehensive resource for clerkship directors across specialties (54). The Clerkship Coordinators Handbook can provide guidance on administrative duties for the rotation (55). Kern’s Curriculum Development in Medical Education: A Six Step Approach provides a practical and systematic way to approach the implementation phase of a curriculum (14). While Kern outlines a broad range of factors that must be taken into account when implementing a curriculum, potential barriers to success merit special consideration. Possibly the biggest challenge is teaching students with differing levels of clinical experience, depending on the timing of the rotation during the third year. Faculty and residents involved in teaching medical students may require guidance in adjusting their expectations and practices to meet the needs of learners in various stages of their training. We chose the ‘‘Must, Should, Can’’ model to allow for this flexibility while maintaining consistency in teaching the core aspects of EM (‘‘Must’’). Novice learners in the ED must be provided with close supervision to ensure patient safety. A second challenge is time constraints in the ED setting. Third-year students may require more faculty and resident guidance than more experienced fourth-year students. They may not have the clinical experience needed to evaluate acuity or independently manage certain aspects of patient care. Balancing the clinical and educational missions of the department is essential, and educators may need to advocate for resources to ensure adequate teaching for their students without compromising departmental operations. Faculty and residents involved with teaching may also require instruction on how to incorporate education for the novice learner into their clinical work in an efficient and effective manner. Third, EM education focuses on high-acuity presentations and stabilization procedures. While it is possible to offer a conceptual background on these topics through

9

lectures or reading, experiential learning techniques are more effective for facilitating mastery of skill objectives (42–44). While labor intensive for faculty, this form of learning is ideal for the third-year student who has not developed the clinical acumen on how to approach high-acuity patients. The benefits are considerable, including improved educational outcomes, high levels of learner satisfaction, and contribution to accreditation performance (29,30). Fourth, it may be difficult to find time for EM in an already crowded third-year medical school schedule. The addition of a required clerkship during this time may require adjustments to another part of the existing curriculum. Potential solutions include an abbreviated 2-week rotation, an elective or selective rotation, or an interdisciplinary rotation with other specialties like surgery, critical care medicine, or anesthesiology (12). Finally, the effect of a third-year EM rotation on an existing fourth-year EM rotation must be considered. The curriculum we provide serves as a basic foundation on which to build and expand the fourth-year experience. Therefore, it is the opinion of this Work Group that this curriculum would enhance rather than diminish the importance of the fourth-year EM rotation. Step 6: Evaluation and Feedback The LCME requires that a medical school ensures a system of formative and summative medical student assessment (22). Whenever possible, multiple methods of assessment should be used, tools should be linked to nationally accepted standards or metrics, and evidence of reliability and validity of assessment data should be assessed and monitored closely (21). Methods of assessment for a third-year EM rotation director to consider are correlated with the content areas listed in Table 1 and Appendixes 1 and 2. These match the categories recommended in the Emergency Medicine Milestones Project (15). Clinical Assessment of the Student Formative feedback should ideally occur regularly throughout the rotation. Daily clinical shift evaluations can provide immediate formative feedback, if discussed with the student at the end of their shift (21). Formal formative mid-rotation feedback needs to be in place for required clerkships lasting 4 weeks or longer, and must be done early enough to allow sufficient time for remediation, ideally at the midpoint of the clerkship (56,57). Clerkship directors should track and document that these sessions have occurred, and be prepared to account for this at future LCME site visits.

10

Compilation of daily scores and narrative comments combined with direct observation and testing form a major component of the summative end of clerkship assessments, including the final grade (58). Direct observation of students engaged in clinical encounters is an LCME requirement for required clerkships, and should be a part of the assessment of students’ clinical performance. Several clinical observation tools have been discussed in the literature, but none of which have demonstrated reliability and validity in the medical student population (59– 62). An example of a direct observation tool can be found in the Medical Student Educators’ Handbook (21). Assessment instruments should be the same for all sites in a multi-site clerkship. The ED can be a challenging environment for clinical assessment. Students rarely work longitudinally with the same preceptor, limiting the observation period on which assessments can be based. The fast pace of the ED makes it difficult to find time to observe students and hear their presentations. The high acuity of ED patients can make it difficult to meaningfully involve novice students in clinical activities, and they are often relegated to an observer role. It is essential that faculty and residents involved with teaching receive education about how to optimize their interactions with students at differing levels of experience in the clinical area, and specific instruction and ‘‘calibration’’ to ensure consistent assessment practices. Nonclinical Assessment of the Student Written, oral, and practical examinations can objectively measure the third-year medical student’s knowledge and skill base. Knowledge can be tested using independently written tests or national examinations. The former can be more readily adjusted to assess unique aspects of individual rotations, while the latter generally have the advantage of greater reliability and validity evidence (9). There are two widely available national examinations: the National EM M4 Exam, which is an online examination recently developed by CDEM (http://www. saemtests.org), and the National Board of Medical Examiners (NBME) Advanced Clinical Exam in EM (63–65). It should be emphasized that both of these examinations are designed based on the curriculum for fourth-year students, and their appropriateness for third-year students has not been established (6,65). Another option for third-year rotation directors is creation of an institutionspecific examination based on the third-year curriculum content. When creating test items for an independently written examination, the NBME Item Writing Manual is a valuable resource to ensure items are of high quality, improving test validity and reliability (9). Simulation-based examinations and Objective Structured Clinical Examinations are particularly well suited

M. C. Tews et al.

to assess psychomotor and problem-solving skills, although they are more resource-intensive than traditional testing methods (66–70). Other assessment techniques may include presentations or reports on EM topics, take-home assignments, such as electrocardiogram and radiology projects, and exercises in evidence-based medicine. For all assessment methods, consideration must be given to ensure test security, to avoid duplication of questions between third- and fourth-year rotations, and to maintain consistency in grading between individuals and sites. Curriculum Maintenance and Enhancement Continuous process improvement is important to ensure a consistently high-quality curricular experience. A thorough description of how to approach this process is outlined by Kern et al. (14). Educators should consider student satisfaction data as well as educational outcome metrics in deciding if and how to revise the rotation. In order to maintain and update this curriculum, the rotation learning objectives and resources will be kept online and periodically updated at http://www.cdemcurriculum.org/. CONCLUSIONS Emergency medicine has increasingly become an established part of medical school curricula, and many institutions teach EM during the third year. The goals and consensus-derived learning objectives provided here form the basis of this third-year EM medical student curriculum. Discussion of educational methods, considerations for implementation, and information regarding feedback and evaluation are included to assist rotation directors in implementing this curriculum at their institutions. To address national standards, LCME guidelines specifically supported by this curriculum are outlined, and may provide additional guidance to programs attempting to establish a third-year EM clerkship. Each institution should review their available resources to ensure the ‘‘Must’’ content areas are covered and look for opportunities to include ‘‘Should’’ and ‘‘Can’’ content where appropriate. REFERENCES 1. Tews MC, Hamilton GC. Integrating emergency medicine principles and experience throughout the medical school curriculum: why and how. Acad Emerg Med 2011;18:1072–80. 2. Wald DA, Lin M, Manthey DE, et al. Emergency medicine in the medical school curriculum. Ann Emerg Med 2010;17:S26–30. 3. Coates WC. An educator’s guide to teaching emergency medicine to medical students. Acad Emerg Med 2004;11:300–6. 4. Khandelwal S, Way DP, Wald DA. State of undergraduate education in emergency medicine: a national Survey of clerkship directors. Acad Emerg Med 2014;21:92–5.

Third-Year EM Medical Student Curriculum 5. Tews MC, Wyte CM, Coltman M, et al. Developing a third-year emergency medicine medical student curriculum: a syllabus of content. Acad Emerg Med 2011;18(Suppl. 2):S36–40. 6. Manthey DE, Ander DS, Gordon DC, et al. Emergency medicine clerkship curriculum: an update and revision. Acad Emerg Med 2010;17:638–43. 7. Coates WC. The emergency medicine subinternship—an educator’s guide to planning and administration. Acad Emerg Med 2005;12: 129e1–4. 8. Manthey DE, Coates WC, Ander DS, et al. Report of the task force on national fourth year medical student emergency medicine curriculum guide. Ann Emerg Med 2006;47:e1–7. 9. Senecal EL, Askew K, Gorney B, Beeson MS, Manthey DE. Anatomy of a clerkship test. Acad Emerg Med 2010;17(Suppl. 2):S31–7. 10. Ten Eyck RP, Tews M, Ballester JM, Hamilton GC. Improved fourth-year medical student clinical decision-making performance as a resuscitation team leader after a simulation-based curriculum. Simul Healthc 2010;5:139–45. 11. Bernard AW, Balodis A, Kman NE, Caterino JM, Khandelwal S. Medical student self-assessment narratives: perceived educational needs during fourth-year emergency medicine clerkship. Teach Learn Med 2013;25:24–30. 12. Mulcare MR, Suh EH, Tews M, Swan-Sein A, Pandit K. Third-year medical student rotations in emergency medicine: a survey of current practices. Acad Emerg Med 2011;18(Suppl. 2):S41–7. 13. Cumyn A, Harris IB. A comprehensive process of content validation of curriculum consensus guidelines for a medical specialty. Med Teach 2012;34:e566–72. 14. Kern D, Thomas P, Hughes M, eds. Curriculum development for medical education: a six step approach. Baltimore, MD: The Johns Hopkins University Press; 2009. 15. American Board of Emergency Medicine. Emergency medicine milestones. Available at: http://www.abem.org/public/publications/ emergency-medicine-milestones. Accessed February 24, 2015. 16. Englander R, Aschenbrener CA, Call SA, et al. Core entrustable professional activities for entering residency. Available at: https://www.mededportal.org/icollaborative/resource/887. Accessed February 24, 2015. 17. McLaughlin SA, Hobgood C, Binder L, Manthey DE, SAEM Undergraduate Education Committee for 2004-2005. Impact of the liaison committee on medical education requirements for emergency medicine education at US schools of medicine. Acad Emerg Med 2005;12:1003–9. 18. Russi CS, Hamilton GC. A case for emergency medicine in the undergraduate medical school curriculum. Acad Emerg Med 2005;12: 994–8. 19. Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical SchoolCambridge integrated clerkship: an innovative model of clinical education. Acad Med 2007;82:397–404. 20. Poncelet A, Bokser S, Calton B, et al. Development of a longitudinal integrated clerkship at an academic medical center. Med Educ Online 2011 Apr 4;16 http://dx.doi.org/10.3402/meo.v16i0.5939. 21. Clerkship Directors in Emergency Medicine/Society for Academic Emergency Medicine. Medical student educators’ handbook. Lansing, MI: Clerkship Directors in Emergency Medicine; 2010. Available at: http://www.cdemcurriculum.org/assets/other/mse_handbook.pdf. Accessed February 24, 2015. 22. Liaison Committee on Medical Education (LCME). Functions and structure of a medical school [liaison committee on medical education web site]. Available at: http://www.lcme.org/publications.htm. Accessed February 24, 2015. 23. Lawshe CH. A quantitative approach to content validity. Personnel Psychol 1975;28:563–75. 24. Council on Medical Student Education in Pediatrics. Curriculum Competencies and Objectives. Available at: http://www.comsep. org/educationalresources/currthirdyear.cfm. Accessed on February 24, 2015. 25. Askew KL, Weiner W, Murphy C, et al. Consensus Development of a Pediatric Emergency Medicine Clerkship Curriculum. West J Emerg Med 2014;15:647–51.

11 26. Clerkship Directors in Emergency Medicine. Emergency medicine clerkship primer: A manual for medical students. Available at: http://www.cdemcurriculum.org/assets/other/ms_primer.pdf. Accessed February 24, 2015. 27. Lin M. Digital instruction in emergency medicine. Available at: http://www.cdemcurriculum.org/diem/diem_entry.html. Accessed February 24, 2015. 28. Pusic MV, Pachev GS, MacDonald WA. Embedding medical student computer tutorials into a busy emergency department. Acad Emerg Med 2007;14:138–48. 29. McLaughlin S, Fitch MT, Goyal DG, et al. Simulation in graduate medical education 2008: a review for emergency medicine. Acad Emerg Med 2008;15:1117–29. 30. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 2005;27:10–28. 31. Driessen EW, van Tartwijk J, Overeem K, Vermunt JD, van der Vleuten CP. Conditions for successful reflective use of portfolios in undergraduate medical education. Med Educ 2005;39: 1230–5. 32. Bernard AW, Gorgas D, Greenberger S, Jacques A, Khandelwal S. The use of reflection in emergency medicine education. Acad Emerg Med 2012;19:978–82. 33. Youngblood P, Harter PM, Srivastava S, Moffett S, Heinrichs WL, Dev P. Design, development, and evaluation of an online virtual emergency department for training trauma teams. Simul Healthc 2008;3:146–53. 34. Smolle J, Prause G, Smolle-Juttner FM. Emergency treatment of chest trauma—an e-learning simulation model for undergraduate medical students. Eur J Cardiothorac Surg 2007;32:644–7. 35. Ricks C, Ratnapalan S, Jain S, Tait G. Evaluating computer-assisted learning for common pediatric emergency procedures. Pediatr Emerg Care 2008;24:284–6. 36. Burnette K, Ramundo M, Stevenson M, Beeson MS. Evaluation of a web-based asynchronous pediatric emergency medicine learning tool for residents and medical students. Acad Emerg Med 2009; 16(Suppl. 2):S46–50. 37. Gisondi MA, Lu DW, Yen M, et al. Adaptation of EPEC-EM curriculum in a residency with asynchronous learning. West J Emerg Med 2010;11:491–9. 38. Fernandez R, Pearce M, Grand JA, et al. Evaluation of a computerbased educational intervention to improve medical teamwork and performance during simulated patient resuscitations. Crit Care Med 2013;41:2551–62. 39. Kelly PA, Haidet P, Schneider V, Searle N, Seidel CL, Richards BF. A comparison of in-class learner engagement across lecture, problem-based learning, and team learning using the STROBE classroom observation tool. Teach Learn Med 2005; 17:112–8. 40. Vernon DT, Blake RL. Does problem-based learning work? A meta-analysis of evaluative research. Acad Med 1993;68: 550–63. 41. Berkson L. Problem-based learning: have the expectations been met? Acad Med 1993;68:S79–88. 42. Wayne DB, Barsuk JH, O’Leary KJ, Fudala MJ, McGaghie WC. Mastery learning of thoracentesis skills by internal medicine residents using simulation technology and deliberate practice. J Hosp Med 2008;3:48–54. 43. Wayne DB, Butter J, Siddall VJ, et al. Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med 2006; 21:251–6. 44. Sawyer T, Sierocka-Castaneda A, Chan D, Berg B, Lustik M, Thompson M. Deliberate practice using simulation improves neonatal resuscitation performance. Simul Healthc 2011;6: 327–36. 45. Stevens LM, Cooper JB, Raemer DB, et al. Educational program in crisis management for cardiac surgery teams including high realism simulation. J Thorac Cardiovasc Surg 2012;144: 17–24.

12 46. Thomas EJ, Williams AL, Reichman EF, Lasky RE, Crandell S, Taggart WR. Team training in the neonatal resuscitation program for interns: teamwork and quality of resuscitations. Pediatrics 2010;125:539–46. 47. Steinemann S, Berg B, Skinner A, et al. In situ, multidisciplinary, simulation-based teamwork training improves early trauma care. J Surg Educ 2011;68:472–7. 48. Yee B, Naik VN, Joo HS, et al. Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education. Anesthesiology 2005;103:241–8. 49. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc 2007;2:115–25. 50. Vivekananda-Schmidt P, Marshall M, Stark P, McKendree J, Sandars J, Smithson S. Lessons from medical students’ perceptions of learning reflective skills: a multi-institutional study. Med Teach 2011;33:846–50. 51. Coates WC, Gill AM, Jordan R. Emergency medicine clerkship directors: defining the characteristics of the workforce. Ann Emerg Med 2005;45:262–8. 52. Pangaro L, Bachicha J, Brodkey A, et al. Expectations of and for clerkship directors: a collaborative statement from the alliance for clinical education. Teach Learn Med 2003;15:217–22. 53. Rogers R, Wald D, Lin M, et al. Expectations of an emergency medicine clerkship director. Acad Emerg Med 2011;18:513–8. 54. Morgenstern B, ed. Alliance for clinical education: guidebook for clerkship directors. North Syracuse, NY: Gegensatz Press; 2012. 55. Clerkship Directors in Emergency Medicine. Clerkship coordinators handbook. Available at: http://www.cdemcurriculum.org/ assets/other/coordinator_handbook.pdf. Accessed February 24, 2015. 56. Pulito AR, Donnelly MB, Plymale M, Mentzer RM Jr. What do faculty observe of medical students’ clinical performance? Teach Learn Med 2006;18:99–104. 57. Bernard AW, Kman NE, Khandelwal S. Feedback in the emergency medicine clerkship. West J Emerg Med 2011;12:537–42. 58. Kogan JR, Shea JA. Implementing feedback cards in core clerkships. Med Educ 2008;42:1071–9.

M. C. Tews et al. 59. Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini-CEX: a method for assessing clinical skills. Ann Intern Med 2003;138:476–81. 60. American Board of Internal Medicine. Mini-clinical evaluation exercise (CEX). Available at: http://www.abim.org/programdirectors-administrators/assessment-tools/mini-cex.aspx. Accessed February 24, 2015. 61. Kogan JR, Bellini LM, Shea JA. Implementation of the mini-CEX to evaluate medical students’ clinical skills. Acad Med 2002;77: 1156–7. 62. Cydulka RK, Emerman CL, Jouriles NJ. Evaluation of resident performance and intensive bedside teaching during direct observation. Acad Emerg Med 1996;3:345–51. 63. National Board of Medical Examiners [NBME]. Emergency medicine advanced clinical exam. Available at: http://www.nbme.org/ Schools/Subject-Exams/Subjects/ace_emergmed.html. Accessed February 24, 2015. 64. Clerkship Directors in Emergency Medicine. National EM M4 exam version 2. Available at: http://www.saemtests.org/. Accessed March 16, 2014. 65. Senecal EL, Thomas SH, Beeson MS. A four-year perspective of society for academic emergency medicine tests: an online testing tool for medical students. Acad Emerg Med 2009;16(Suppl. 2): S42–5. 66. Hall AK, Pickett W, Dagnone JD. Development and evaluation of a simulation-based resuscitation scenario assessment tool for emergency medicine residents. CJEM 2012;14:139–46. 67. Michelson JD, Manning L. Competency assessment in simulationbased procedural education. Am J Surg 2008;196:609–15. 68. Lammers R, Davenport M, Korley F. Teaching and assessing procedural skills using simulation: metrics and methodology. Acad Emerg Med 2008;15:1079–87. 69. Prislin MD, Fitzpatrick CF, Lie D, Giglio M, Radecki S, Lewis E. Use of an objective structured clinical examination in evaluating student performance. Fam Med 1998;30:338–44. 70. Distlehorst L, Dunnington G, Folse J, eds. Teaching and learning in medical and surgical education: lessons learned for the 21st century. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2000.

Content The Approach to the Undifferentiated Patient Stabilization of the Acutely Ill Patient

Vital Signs

Basic and Advanced Life Support Techniques

Focused Chief Complaint History and Physical (H&P) Examination

Chief Complaint Differential Diagnosis

Revised Learning Objectives

Educational Methods*

Already covered in ‘‘must’’ objectives. 1. Identify potential causes L, IS of acute blood loss in gastrointestinal (GI) bleeding. 2. Describe the clinical approach to the bleeding patient. 1. Define a hypertensive L, IS crisis.

1. Demonstrate how to L, S, EL perform electrical cardioversion in the appropriate clinical setting. 2. Demonstrate how to perform transcutaneous pacing in the appropriate clinical setting. 1. Perform a focused H&P L, IS, C, S, EL, SG for a patient presenting with: a. Headache b. Focal neurologic deficit c. GI bleeding d. Vaginal bleeding/ pelvic pain e. Toxic ingestion 1. List the common and life-threatening causes of: a. Headache b. Focal neurologic deficit c. GI bleeding d. Vaginal bleeding/ pelvic pain e. Toxic ingestion

L, C, E, SG, S, IS

Assessment Methods†

ACGME Competencies, ABEM Milestones,‡ and EPA§

References

C, G, OSCE, Sim, SOE, MCQ

PC-1, 2, 3, 4, 5, 6, 7 MK

CDEM: Stabilization of the Acutely Ill Patient; Approach to: Shock; Approach to Gastrointestinal bleeding; Approach to: Trauma

SOE, MCQ, EOS

PC-1 MK

C, G, Sim, MCQ

PC-1,4,6, 9 MK ICS-2

EMCP: Chapter 11: Developing Your Plan of Action CDEM: Approach to the Undifferentiated Patient CDEM: Basic and Advanced Life Support Current BLS/ACLS/PALS guidelines

C, G, OSCE, Sim, SOE, SP, MCQ, EOS, BE

PC-2 MK PBLI

C, Sim, SOE, MCQ, EOS

PC-4 MK PBLI

Third-Year EM Medical Student Curriculum

Appendix 1. ‘‘Should’’ Third-Year EM Curriculum Content

EMCP: Chapter 7: Performing a Complaint Directed H&P, and Chapter 8: Data Gathering Skills, and Chapter 11: Developing Your Plan of Action CDEM: The Approach to: Headache, Neurologic Complaint, GI Bleed, Vaginal Bleeding/Pelvic Pain, Poisoning EMCP: Chapter 9: Developing a Case-Specific Differential Diagnosis CDEM: The Approach to: Headache, Neurologic Complaint, GI Bleed, Vaginal Bleeding/Pelvic Pain, Poisoning

Continued

12.e1

Appendix 1. Continued

Diagnostic testing

Electrocardiogram (ECG)/ Rhythm Recognition

Educational Methods*

Laboratory studies L, C, SG, Sim, IS 1. Describe the indications and uses of the following laboratory studies, and what is considered normal vs. abnormal: a. Arterial blood gas b. D-dimer c. Quantitative b-HCG Radiographic studies 1. Discuss the use of clinical decision rules for determining which patients with traumatic brain injury require a noncontrast head computed tomography (CT) scan 2. Interpret a noncontrast CT scan of the head for the different types (epidural, subdural, subarachnoid, intraparenchymal) of intracranial bleeding Bedside testing 1. Describe the indications and interpretation of a stool guaiac test for a patient with potential GI bleeding 1. Identify the following L, IS, S, EL rhythms on ECG or rhythm strip and describe their initial treatment: a. Supraventricular tachycardia b. Atrial fibrillation c. Atrial flutter d. Second- and thirddegree heart block 1. Discuss the manageL, IS, C, S, EL ment of a subcutaneous abscess 2. Discuss the indications and contraindications of a lumbar puncture for a patient with a headache

Assessment Methods†

ACGME Competencies, ABEM Milestones,‡ and EPA§

References

Sim, SOE, MCQ, EOS

PC-3 MK SBP-1, 2, 3

EMCP: Chapter 10: Diagnostic Testing in the Emergency Department CDEM: Diagnostic Testing

Sim, SOE, MCQ, EOS, BE

PC-3,4, 5 MK SBP-1

CDEM: Approach to: Cardiac Arrest, Diagnostic Testing Current BLS/ACLS guidelines

C, G, Sim, SOE, MCQ, EOS, BE

PC-9, 13 MK SBP-1

EMCP: Chapter 20: Procedural Skills CDEM: Procedures

M. C. Tews et al.

Emergency Department (ED) Procedures

Revised Learning Objectives

12.e2

Content

Acute Pain Control Bedside Ultrasonography

Documentation (when applicable)

Disposition

1. Describe the initial L, IS, C, S management of extremity fractures and dislocations 2. Demonstrate the correct technique for immobilization of the spine 3. List the criteria (NEXUS or Canadian) for identifying which patients require cervical spine imaging vs. those who can be cleared clinically. 4. Demonstrate clinical assessment of the spine and removal of cervical collar and backboard when indicated Already covered in ‘‘must’’ objectives 1. Discuss the indications L, IS, EL, C, S, SG for bedside ultrasound in the ED 2. Describe the indications for obtaining a bedside ultrasound evaluating for a pericardial effusion 3. Describe the indications for obtaining a bedside ultrasound evaluating for an abdominal aortic aneurysm 1. Document pertinent L, C, S, SG positives and negatives from a focused history and physical examination for a patient with: a. Headache b. Focal neurologic deficit c. Gastrointestinal bleeding d. Vaginal bleeding/ pelvic pain e. Toxic ingestion Already covered in ‘‘must’’ objectives

C, G, Sim, SOE, SP, MCQ

PC-1, 3, 4, 9, MK ICS-2 SBP-1, 2

CDEM: The Approach to Trauma; Procedures

C, G, Sim, SOE, MCQ

PC-3,14 MK PBLI

CDEM: Diagnostic Testing

RR, Sim, SP, MCQ, EOS

PC-2, 6 MK SBP-2,3

EMCP: Chapter 15: Documentation CDEM: Documentation of EM Encounters

12.e3

Continued

Third-Year EM Medical Student Curriculum

Traumatic and Orthopedic Injuries

Appendix 1. Continued Revised Learning Objectives

Educational Methods*

Emergency Medicine within the US Healthcare System

1. Explain the use of a L, IS, SG systems approach to patient care (STEMI, stroke, trauma, etc.) 2. Describe EMTALA guidelines and how it relates to ED transfers of patients

Emergency Medical Services

Already covered in ‘‘must’’ objectives Discuss the role of the L, IS, R, C, S emergency physician in dealing with challenging situations in the ED (e.g., victims of child abuse, elder abuse, sexual assault, emancipated minors, patients who refuse medical care) 1. Discuss strategies for L, IS, R, C, S delivering bad news 2. Discuss strategies for dealing with consultants 3. Discuss the importance of safe handoff strategies

Professionalism

Communication

Motivation

1. Demonstrate follow IS, R, C through on admitted patient’s hospital course

Assessment Methods†

ACGME Competencies, ABEM Milestones,‡ and EPA§

References

SOE, MCQ

PC-1 MK PBLI SBP-2

EMCP: Chapters 1: Introduction to the Specialty of EM and Chapter 4: Unique Educational Aspects of Emergency Medicine and Chapter 5: Differences between the ED, the Office and the Inpatient Setting CDEM: Emergency Medicine in the US Healthcare System

C, G, OSCE, RR, SOE, SP, MCQ, EOS, BE

PC-1, 2, 3, 4 MK ICS-1, 2 PROF-1, 2 SBP-1, 2

EMCP: Chapter 23: Introduction to the Core Competencies CDEM: Professionalism

C, G, OSCE, RR, SOE, SP, MCQ, EOS, BE

PC-1, 6, 7 PBLI ICS-1,2 PROF-1, 2SBP-2

C, G, L, RR, EOS

PBLI PROF-1,2 SBP-2

EMCP: Chapter 17: Interacting with Consultants and Primary Care Physicians and EMCP: Chapter 23: Introduction to the Core Competencies CDEM: Communication EMCP: Chapter 22: How to Get the Most Out of Your Emergency Medicine Clerkship

M. C. Tews et al.

ABEM = American Board of Emergency Medicine; ALS = advanced life support; ACGME = Accreditation Council for Graduate Medical Education; BLS = basic life support; CDEM = CDEMcurriculum.org; EMCP = Emergency Medicine Clerkship Primer; EMTALA = Emergency Medical Treatment and Labor Act; EPA = Entrustable Professional Activities; HCG = human chorionic gonadotropin; PALS = pediatric advanced life support; STEMI = ST segment elevation myocardial infarction; US = United States. * C = clinical ED setting; E = E-learning; IS = independent study/reading; L = lecture; R = reflection; S = simulation; SG = small group sessions. † C = checklist evaluation of live or recorded performance (e.g., SDOT, Mini-Clinical Evaluation Exercise); BE = bedside evaluations; DO = direct observation; EOS = end of shift evaluations; G = Global rating of live or recorded performance; L = procedure or case logs; MCQ = written examination; OSCE = objective structured clinical examination or standardized patients; P = portfolios; RR = record review; S = patient surveys; Sim = simulations and task trainers; SOE = standardized oral examination. ‡ ICS = interpersonal and communication skills; MK = medical knowledge; PBLI = practice-based learning and improvement; PC = patient care; PRO = professionalism; SBP = systembased practice; PC-1 = Emergency Stabilization; PC-2 = Performance of a Focused History and Physical; PC-3 = Diagnostic Studies; PC-4 = Diagnosis; PC-5 = Pharmacotherapy; PC-6 = Observation and Reassessment; PC-7 = Disposition; PC-8 = Multi-tasking; PC-9 = General Approach to Procedures; PC-10 = Airway Management; PC-11 = Anesthesia and Acute Pain Management; PC-12 = Goal Directed Focused Ultrasound; PC-13 = Wound Management; PC-14 = Vascular Access; MK = Medical Knowledge; PROF-1 = Professional Values; PROF-2 = Accountability; ICS-1 = Patient Centered Communication; ICS-2 = Team Management; PBLI = Practiced Based Performance Improvement; SBP-1 = Patient Safety; SBP-2 = Systems Based Management; SBP-3 = Technology. § EPA 1 = Gather a history and perform a physical examination; EPA 2 = Develop a prioritized differential diagnosis and select a working diagnosis following a patient encounter; EPA 3 = Recommend and interpret common diagnostic and screening tests; EPA 5 = Provide documentation of a clinical encounter in written or electronic format; EPA 7 = Form clinical questions and retrieve evidence to advance patient care; EPA 9 = Participate as a contributing and integrated member of an interprofessional team; EPA 10 = Recognize a patient requiring urgent or emergent care, initiate evaluation and treatment, and seek help; EPA 12 = Perform general procedures of a physician.

12.e4

Content

Content The Approach to the Undifferentiated Patient Stabilization of the Acutely Ill Patient

Vital Signs Basic and Advanced Life Support Techniques

Focused Chief Complaint History and Physical Examination Chief Complaint Differential Diagnosis Diagnostic Testing

Electrocardiogram (ECG)/ Rhythm Recognition

Emergency Department (ED) Procedures

Revised Learning Objectives

Educational Methods*

Already covered in ‘‘must’’ or ‘‘should’’ objectives. 1. Describe the approach L, IS and stabilization of the traumatically injured patient with acute blood loss. Already covered in ‘‘must’’ or ‘‘should’’ objectives. 1. List the steps in rapid L, S, EL sequence intubation. 2. Demonstrate the technique for placement of an endotracheal tube. 3. Explain the purpose and uses of bilevel positive airway pressure. Already covered in ‘‘must’’ or ‘‘should’’ objectives.

ACGME Competencies, ABEM Milestones,‡ and EPA§

References

C, G, OSCE, Sim, SOE, MCQ

PC-1, 5, 6 MK

CDEM: Stabilization of the Acutely Ill Patient; Approach to: Shock; Approach to Gastrointestinal bleeding; Approach to: Trauma

C, G, Sim, MCQ

PC-10 MK

Current BLS/ACLS/PALS guidelines CDEM: Basic and Advanced Life Support

Sim, SOE, MCQ, EOS

PC-3 MK SBP-2,3

EMCP: Chapter 10: Diagnostic Testing in the Emergency Department CDEM: Diagnostic Testing

Sim, SOE, MCQ, EOS, BE

PC-3,4,5 MK

CDEM: Approach to: Cardiac Arrest, Current BLS/ACLS guidelines CDEM: Diagnostic Testing

C, G, Sim, SOE, MCQ, EOS, BE

PC-9,12,14 MK

EMCP: Chapter 20: Procedural Skills CDEM: Procedures

12.e5

Already covered in ‘‘must’’ or ‘‘should’’ objectives. Laboratory studies L, C, SG, Sim, IS 1. Describe the indications, utilization, and interpretation of a btype natriuretic peptide 1. Identify the following L, IS, S, EL patterns on ECG or rhythm strip and describe their clinical significance and initial treatment: a. Wolf-Parkinson White syndrome b. Brugada syndrome c. Osborn waves d. Hypo- and hyperkalemia e. Hypo- and hypercalcemia 1. Describe the indicaL, IS, C, S, EL tions, contraindications and correct technique for placing a central venous line (see Bedside Ultrasonography).

Assessment Methods†

Third-Year EM Medical Student Curriculum

Appendix 2. ‘‘Can’’ Third-Year Emergency Medicine Curriculum Content

Acute Pain Control Bedside Ultrasonography

Documentation Disposition Emergency Medicine within the US Healthcare System

Emergency Medical Services (EMS)

1. Describe the approach L, IS, C, S to the traumatically injured patient with blunt and penetrating trauma. 2. Demonstrate a primary and secondary survey in a traumatically injured patient. Already covered in ‘‘must’’ or ‘‘should’’ objectives. 1. Describe the indications L, IS, EL, C, S, SG for obtaining a bedside ultrasound in trauma. 2. Define a positive FAST examination in the setting of trauma. 3. Describe the use of ultrasound in the placement peripheral and central venous lines. Already covered in ‘‘must’’ or ‘‘should’’ objectives. Already covered in ‘‘must’’ or ‘‘should’’ objectives. 1. Discuss the history of L, IS, SG emergency medicine and its evolution into a medical specialty. 2. Discuss the types of career opportunities available in EM.

PC-1,2 MK SBP-2,3

CDEM: The Approach to Trauma; Traumatic and Orthopedic Procedures

C, G, Sim, SOE, MCQ

PC-3,14 MK PBLI

CDEM: Diagnostic Testing

SOE, MCQ

MK PBLI SBP-2

SOE, MCQ

PC-1 MK PBLI SBP-1,2

EMCP: Chapters 1: Introduction to the Specialty of EM and Chapter 4: Unique Educational Aspects of Emergency Medicine and Chapter 5: Differences between the ED, the Office and the Inpatient Setting CDEM: Emergency Medicine in the US Health Care System CDEM: Emergency Medicine in the US Health Care System

Continued

M. C. Tews et al.

1. Describe the function of L, IS, SG EMS in the health care system. 2. Differentiate between basic and advanced life support transport in the prehospital setting. 3. Discuss the factors that go into deciding to transport a patient by ground vs. air. 4. Discuss regional trauma center designations and the decision where to transport an injured patient.

C, G, Sim, SOE, SP, MCQ

12.e6

Traumatic/Orthopedic Injuries

Content Professionalism Communication Motivation

Revised Learning Objectives

Educational Methods*

Assessment Methods†

ACGME Competencies, ABEM Milestones,‡ and EPA§

References

Already covered in ‘‘must’’ or ‘‘should’’ objectives. Already covered in ‘‘must’’ or ‘‘should’’ objectives. Already covered in ‘‘must’’ or ‘‘should’’ objectives.

ABEM = American Board of Emergency Medicine; ALS = advanced life support; ACGME = Accreditation Council for Graduate Medical Education; BLS = basic life support; CDEM = CDEMcurriculum.org; EMCP = Emergency Medicine Clerkship Primer; FAST = focused assessment with sonography in trauma; PALS = pediatric advanced life support; US = United States. * C = clinical ED setting; E = E-learning; IS = independent study/reading; L = lecture; R = reflection; S = simulation; SG = small group sessions. † C = checklist evaluation of live or recorded performance (e.g., SDOT, Mini-Clinical Evaluation Exercise); BE = bedside evaluations; DO = direct observation; EOS = end of shift evaluations; G = Global rating of live or recorded performance; L = procedure or case logs; MCQ = written examination; OSCE = objective structured clinical examination or standardized patients; P = portfolios; RR = record review; S = patient surveys; Sim = simulations and task trainers; SOE = standardized oral examination. ‡ ICS = interpersonal and communication skills; MK = medical knowledge; PBLI = practice-based learning and improvement; PC = patient care; PRO = professionalism; SBP = systembased practice; PC-1 = Emergency Stabilization; PC-2 = Performance of a Focused History and Physical; PC-3 = Diagnostic Studies; PC-4 = Diagnosis; PC-5 = Pharmacotherapy; PC-6 = Observation and Reassessment; PC-7 = Disposition; PC-8 = Multi-tasking; PC-9 = General Approach to Procedures; PC-10 = Airway Management; PC-11 = Anesthesia and Acute Pain Management; PC-12 = Goal Directed Focused Ultrasound; PC-13 = Wound Management; PC-14 = Vascular Access; MK = Medical Knowledge; PROF-1 = Professional Values; PROF-2 = Accountability; ICS-1 = Patient Centered Communication; ICS-2 = Team Management; PBLI = Practiced Based Performance Improvement; SBP-1 = Patient Safety; SBP-2 = Systems Based Management; SBP-3 = Technology. § EPA 1 = Gather a history and perform a physical examination; EPA 2 = Develop a prioritized differential diagnosis and select a working diagnosis following a patient encounter; EPA 3 = Recommend and interpret common diagnostic and screening tests; EPA 5 = Provide documentation of a clinical encounter in written or electronic format; EPA 7 = Form clinical questions and retrieve evidence to advance patient care; EPA 9 = Participate as a contributing and integrated member of an interprofessional team; EPA 10 = Recognize a patient requiring urgent or emergent care, initiate evaluation and treatment, and seek help; EPA 12 = Perform general procedures of a physician.

Third-Year EM Medical Student Curriculum

Appendix 2. Continued

12.e7

12.e8

M. C. Tews et al.

Appendix 3. Liaison Committee on Medical Education Requirements Addressed by Third-Year Emergency Medicine Curriculum* (22) LCME

Implication

Support Provided by This Curriculum

ED-1

Faculty must define the objectives for curriculum content and provide the basis for evaluating the effectiveness of the educational program.

ED-1A

Objectives of the educational program must be stated in outcome-based terms that allow evaluation of the student’s progress.

ED-3

The objectives of the program must be made known to all students and to faculty and residents responsible for the medical student education.

ED-8

There must be comparable educational experiences and equivalent methods of evaluation across all sites in a multisite rotation.

ED-19

Medical schools must offer specific instruction in communication skills.

ED-27

There must be ongoing assessment that assures students have acquired the core clinical skills, behaviors, and attitudes specified in the educational objectives.

ED-30

Clerkship directors must implement a system of formative and summative evaluation of student achievement in each clerkship

ED-31

Medical students must receive feedback early enough to allow time for remediation

ED-34

The program’s faculty is responsible for the design and implementation of the curriculum, including the development of specific course objectives and evaluation methods to assess achievement of these objectives, and assessment of course and teacher quality.

In developing this curriculum, our consensus group determined which elements of knowledge, skills, and attitudes were appropriate to teach third-year medical students and developed these into measurable learning objectives for educators to use. This curriculum lists the learning objectives in outcome-based terms. Various assessment tools are identified that allow evaluation of the medical student’s performance and progression throughout the clerkship. This curriculum delineates specific learning objectives in outcome-based terms that can be shared with the medical students, supervising residents, and attending physicians to ensure consistent education and evaluation of the students. This curriculum was designed to insure that all third-year medical student emergency medicine (EM) clerkships have consistent achievable objectives across all institutional sites (‘‘Must’’ objectives). These should be assessed by using daily shift evaluation forms as well as end of clerkship summative assessments. These forms should be consistent across sites. EM allows students to observe and practice a wide range of doctor–patient and inter-professional communication skills. The emergency department provides vast opportunity to teach and assess student’s communication skills with these interactions and is a necessary component of this curriculum. The learning objectives in this curriculum delineate the knowledge, skills, and attitudes taught in this curriculum. We suggest various methods for assessing the acquisition of these objectives, including direct observation, formative and summative evaluations and written exams. Daily clinical shift forms provide formative feedback. Compilation of these daily scores and narrative comments combined with direct observation and testing form the basis for summative assessment resulting in the final grade as well as mid- and end-of-clerkship feedback. The structure of EM allows students to be evaluated by supervising residents and faculty on each shift. Written and real-time feedback provides continuous performance data that can be used during mid-rotation feedback to identify areas in need of remediation. This curriculum includes learning objectives that were deemed necessary (‘‘Must’’) for third year medical students by consensus agreement of experts in the field of EM education. Additional objectives for faculty to choose from are included in the ‘‘Should’’ and ‘‘Can’’ content, which can be chosen based on department or institutional resources. Methods of evaluation have been cited in the EM literature and students must also have the opportunity to evaulate the teachers and the clerkship.

* Since submission of this article, the Liaison Committee on Medical Education has modified their standards. The new standards publication is effective for the 2015-16 academic year and has a useful table that compares these 2014-15 standards to the updated standards.