The Journal of Emergency Medicine, Vol. 47, No. 3, pp. 328–332, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.04.029
Education MEDICAL STUDENT EDUCATION IN EMERGENCY MEDICINE: DO STUDENTS MEET THE NATIONAL STANDARDS FOR CLINICAL ENCOUNTERS OF SELECTED CORE CONDITIONS? Jennifer Avegno, MD,* Amy Leuthauser, MD,† Joseph Martinez, MD,‡ Melissa Marinelli, MD,§ Gale Osgood, MD,k Robert Satonik, MD,{ and Doug Ander, MD** *Department of Emergency Medicine, LSU-New Orleans, New Orleans, Louisiana, †Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York, ‡Department of Emergency Medicine, University of Maryland, Baltimore, Maryland, §Department of Emergency Medicine, Northwestern University, Chicago, Illinois, kDepartment of Emergency Medicine, University of Missouri-Columbia, Columbia, Missouri, {Synergy Medical, Mount Pleasant, Michigan, and **Department of Emergency Medicine, Emory University, Atlanta, Georgia Reprint Address: Jennifer Avegno, MD, Department of Emergency Medicine, LSU-New Orleans, 1542 Tulane Avenue, New Orleans, LA 70112
, Abstract—Background: Establishing a core curriculum for undergraduate Emergency Medicine (EM) education is crucial to development of the specialty. The Clerkship Directors in Emergency Medicine (CDEM) National Curriculum Task Force recommended that all students in a 4th-year EM clerkship be exposed to 10 emergent clinical conditions. Objectives: To evaluate the feasibility of encountering recommended core conditions in a clinical setting during a 4th-year EM clerkship. Methods: Students from three institutions participated in this ongoing, prospective observation study. Students’ patient logs were collected during 4-week EM clerkships between July 2011 and June 2012. Deidentified logs were reviewed and the number of patient encounters for each of the CDEM-identified emergent conditions was recorded. The percentage of students who saw each of the core complaints was calculated, as was the average number of core complaints seen by each. Results: Data from 130 students at three institutions were captured; 15.4% of students saw all 10 conditions during their rotation, and 76.9% saw at least eight. The average number of conditions seen per student was 8.4 (range of 7.0–8.6). The percentage of students who saw each condition varied, ranging from 100% (chest pain and abdominal pain) to 31% (cardiac arrest). Conclusions: Most students do not encounter all 10 conditions during patient encounters throughout a 4-week EM rotation, although most have exposure to at least eight. Certain conditions are far less likely
than others to be encountered, and may need to be taught in a nonclinical setting. Ó 2014 Elsevier Inc. , Keywords—medical conditions
student;
education;
clinical
INTRODUCTION Clerkship directors and educators aim to provide all students with an educationally meaningful rotation in Emergency Medicine (EM). To do so, student exposure to a sufficient variety of patient complaints is essential. Establishing a core curriculum for undergraduate EM education across the country is crucial to uniform development of the specialty. The Clerkship Directors in Emergency Medicine (CDEM) National Curriculum Task Force recommends that all students in a 4th-year EM clerkship be exposed to 10 emergent clinical conditions (1). These core patient encounters form the basis for a suggested EM curriculum, both clinical and didactic. The Liaison Committee on Medical Education requirements for EM also encourage clerkship directors to provide specific rotation objectives, logs to document exposure, and supplementation with didactics or simulation any topics not encountered clinically (2).
RECEIVED: 12 June 2013; FINAL SUBMISSION RECEIVED: 6 February 2014; ACCEPTED: 28 April 2014 328
Medical Student Education in Emergency Medicine
Previous research has established that a standard student experience can be provided on an EM rotation, given good planning and targeted goals and objectives (3). The use of logbooks to document encounters has been used as a surrogate marker of rotation quality. A study by McGraw and Lord in Canada compared student logbooks of clinical encounters and procedures and compared them to what their faculty considered to be the six most important clinical encounters and five most important procedures. In a 2-week clerkship, several deficiencies in student experiences were found, and these prompted a reappraisal of the program’s objectives (4). A similar study in internal medicine using an electronic logbook to track patient encounters of 18 different training problems published by the Clerkship Directors in Internal Medicine found that 98% of students across six campuses were able to meet prespecified criteria for the number and type of patient encounters (5). None of the previous published research has evaluated students’ likelihood of encountering the CDEM task force’s recommended core conditions in a clinical setting. The purpose of this study was to evaluate whether these recommendations are being met across different clinical and academic sites. We hypothesized that all students would be exposed to all 10 emergent clinical conditions during an EM rotation. If all recommended patient presentations cannot be met via clinical exposure alone, educational techniques may be necessary to ensure a standard experience for every medical student, or modifications of the national syllabus could be considered. METHODS Students from three medical schools participated in this ongoing, prospective observation study. Student data were collected from rotations at three institutions. The rotation at Institution 1 is a mandatory rotation comprised of 14 8-h shifts at an urban, academic emergency department (ED) with a total patient volume of 100,000 visits per year. Both Institutions 2 and 3 send students to rotate in a single urban, academic ED with a patient volume of 70,000 per year, and students work between 9 and 12 12-h shifts. The rotation at Institution 3 is an elective, whereas the rotation at Institution 2 is mandatory. There are EM
329
residents rotating at all three sites. All students were required to complete patient logs during their EM rotation. Rotators entered the chief complaint or diagnosis on each patient encounter using free text. Student instructions on how to enter and complete logs were identical across the three sites, and the logs were standardized across participating institutions. Students were not mandated to see any particular patient or condition, though students at Institution 1 were required to see at least 60 patients per rotation. Patient logs from students collected during their 4week EM clerkships between July 2011 and June 2012 at clinical sites associated with the participating medical schools were pooled and analyzed. At all three sites, the students are mandated to record every patient encounter. Students were not aware of the 10 core conditions during their rotation, and there was no requirement to see any particular complaint. The de-identified logs were reviewed by the investigator at each site and the number of patient encounters for each of the CDEM-identified emergent conditions was recorded. The percentage of students who saw each of the 10 core complaints was calculated. The average number of core complaints seen by each student, as well as the percentage of students who saw each complaint, was also calculated. RESULTS Data were collected from 130 students at three institutions; 15.4% of the students saw all 10 conditions, and 76.9% of students saw eight or more of the conditions during their clerkship (Table 1). The smallest number seen over 4 weeks was five conditions (one student), with five other students seeing only six conditions. The number of students encountering eight or more conditions varied by location. Institution 1 had the largest number of 4-week rotators, and here, the percent of students encountering eight or more conditions was 85.7%, whereas this number was 40% at the other two institutions. Some conditions were encountered more frequently than others (Table 2). All students in the study encountered at least one patient with abdominal pain and one patient with chest pain during their month. Trauma, altered
Table 1. Student Clinical Exposure to Core Complaints
Institution 1 Institution 2 Institution 3 All
# of 4-Week Students
% of Students Encountering All 10 Core Complaints
% of Students Encountering 8 or More Core Complaints
Average # of Core Complaints Seen/Student
Range
105 10 15 130
16.2 10.0 13.3 15.4
85.7 40.0 40.0 76.9
8.6 7.7 7.0 8.4
7–10 6–10 5–9 5–10
330
J. Avegno et al.
Table 2. Frequency of Encountering Core Conditions Condition
Average Number of Times Core Complaint was Encountered
Range
Standard Deviation
% of All Students Seeing Condition
Abdominal pain Altered mental status Cardiac arrest Chest pain Gastrointestinal bleeding Headache Poisoning Respiratory distress Shock Trauma
8.5 4.2 0.5 5.4 1.4 2.0 1.7 4.4 1.2 7.9
2–20 0–16 0–3 1–14 0–5 0–7 0–13 0–11 0–7 0–20
3.7 2.5 0.8 2.6 1.3 1.5 1.8 2.4 1.1 3.8
100 98 32 100 72 87 77 96 75 99
mental status, and respiratory distress were all encountered at least one time by more than 96% of students. Only cardiac arrest was encountered by < 70% of students, regardless of site. Exposure for some conditions did vary widely by location, though most rates were fairly consistent across sites. The number of times each condition was encountered varied greatly as well (Table 2). Abdominal pain and trauma were seen the largest number of times, an average of 8.5 and 7.9 times, respectively. Chest pain, respiratory distress, and altered mental status were seen four to six times per block, on average, with all other conditions averaging fewer than two encounters per rotation. DISCUSSION EM clerkship rotations provide students with a breadth of patient encounters, clinical learning activities, and exposure to management of acute emergencies not always found in other clerkships (1,2,5,6,7). In one study, students on an EM rotation were also significantly more likely to perform an initial evaluation and participate in diagnosis and management decisions than those in an internal medicine (IM) clerkship (8). Other studies have attempted to define a core set of expected patient encounters for medical students in the ED. A 1989 paper using American College of Emergency Physicians curriculum recommendations looked at 32 different categories of patient complaints, and found that only seven were able to reach 80% student penetrance (i.e., only seven categories were seen by at least 80% of all students on the rotation) (9). In our study, six of the 10 core conditions were seen by at least 80% of students. Unsurprisingly, the least-encountered condition was cardiac arrest (only 32% of students), with gastrointestinal bleeding, poisoning, and shock each encountered by roughly three-fourths of students. Similar to other research, 100% of students encountered patients with chest pain and abdominal pain, with variable exposure to other relatively common complaints like shortness of breath, headache, and fever (4).
Other studies have looked at the feasibility of students encountering predetermined core patient presentations while on an EM rotation. One paper examined 10 common chief complaints and found that only 32% of students who were required to see all 10 complaints were actually able to fulfill that requirement (though 79% were able to see nine of 10) (10). In another, only 50% of students documented exposure to at least one patient with each of six core conditions (11). In our study, 15.4% of students encountered all 10 patient presentations, but over 95% saw seven or more. There was some variability based on site in our study: Institution 1 students saw more patients on average per shift, and had a higher percentage of students encountering seven or more core conditions, than did students at the other two institutions. This counters the findings of an IM clerkship performed across sites that found excellent concordance between sites on students’ ability to encounter core presentations (5). However, those were mandated encounters, whereas students in our study were not required to see any particular patient presentation(s). Ensuring a standard experience and clinical exposures for all students, then, may be variable without careful planning and curricular adjustment. Because few clerkships can likely meet targets for clinical exposures, educators should be aware of those presentations least likely to be encountered on shift, and augment these with didactic offerings (9). Students who participated in an EM rotation that included skills laboratories, simulation, tutorials, and other adjunctive learning activities in addition to clinical work valued active experiences (such as Advanced Cardiac Life Support and procedure laboratories) highly (12). Based on our results, a simulated cardiac arrest case would be a high-yield component of an EM rotation. Limitations Our article has several limitations. Investigators did not independently verify the data in the students’ patient logs for accuracy. There was also no specific amount of
Medical Student Education in Emergency Medicine
patient responsibility required for students to log exposure to that condition. It is possible that some students may have logged conditions to which they were exposed in more of a shadowing capacity as opposed to true patient responsibility. However, it would be unusual for students to have significant amounts of responsibility for some of these conditions (e.g., cardiac arrest), and meaningful education can be obtained from patient encounters even without true primary responsibility for those patients. Furthermore, one institution (#1) accounted for the majority of students, and the number of rotators was much smaller at Institutions 2 and 3. This variance may have skewed the data and may decrease the applicability of these data to widespread utility across varied institutions. Institution 1 also has the highest patient volumes (100,000 visits per year vs. 70,000). This raises the possibility that larger patient volumes may lead to exposure to more conditions. If this finding were borne out in future studies, it could have implications for clerkships at smaller institutions. Continued data acquisition and participation by other institutions is planned and may further elucidate whether this is a true finding inherent to EM rotations, or merely an institutional difference. Finally, students were not given specific instructions on how to categorize certain presentations. For example, one student caring for a patient with alcohol intoxication may log this as ‘‘poisoning,’’ whereas another student may log this as ‘‘altered mental status’’ and a third student may log it as both. The lack of standardization of terminology is inherent in the CDEM guidelines. It would be challenging for any set of guidelines to be standardized nationwide. CONCLUSION The vast majority of students do not encounter all 10 conditions in actual patient encounters during a 1-month emergency medicine rotation, although most have expo-
331
sure to at least eight. Certain conditions, most notably cardiac arrest, are far less likely than others to be encountered, and should be taught in a nonclinical setting to meet CDEM recommendations. Clerkship directors should actively monitor their students’ exposure to various emergency conditions and supplement live clinical encounters with other didactic modalities. REFERENCES 1. Manthey DE, Ander DS, Gordon DC, et al. Clerkship Directors in Emergency Medicine (CDEM) Curriculum Revision Group. Emergency medicine clerkship curriculum: update and revision. Acad Emerg Med 2010;17:638–43. 2. 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 U.S. schools of medicine. Acad Emerg Med 2005;12:1003–9. 3. Coates W. An educator’s guide to teaching emergency medicine to medical students. Acad Emerg Med 2004;11:300–6. 4. McGraw R, Lord JA. Clinical activities during a clerkship rotation in Emergency Medicine. J Emerg Med 1997;15:557–62. 5. Ferenchick G, Mohmand A, Mireles J, Solomon D. Using patient encounter logs for mandated clinical encounters in an Internal Medicine clerkship. Teach Learn Med 2009;21:299–304. 6. Russi CS, Hamilton G. A case for emergency medicine in the undergraduate medical school curriculum. Acad Emerg Med 2005;12: 994–8. 7. Burdick WP, Jouriles NJ, D’Onofrio G, Kass LE, Mahoney JF, Restifo KM. Emergency medicine in undergraduate education. Acad Emerg Med 1998;5:1105–10. 8. Johnson GA, Pipas L, Newman-Palmer NB, Brown LH. The emergency medicine rotation: a unique experience for medical students. J Emerg Med 2002;22:307–11. 9. DeLorenzo RA, Mayer D, Geehr EC. Analyzing clinical case distributions to improve an emergency medicine clerkship. Ann Emerg Med 1990;19:746–51. 10. Lampe CJ, Coates WC, Gill AM. Emergency medicine subinternship: does a standard clinical experience improve performance outcomes? Acad Emerg Med 2008;15:82–5. 11. Coates WC, Gendy MS, Gill AM. Emergency medicine subinternship: can we provide a standard clinical experience? Acad Emerg Med 2003;10:1138–41. 12. Yeung M, Beecker J, Marks M, et al. A new emergency medicine clerkship program: students’ perceptions of what works. CJEM 2010;12:212–9.
332
J. Avegno et al.
ARTICLE SUMMARY 1. Why is this topic important? This topic has relevance for emergency medicine clerkships around the county. The results may encourage programs to make modifications to their didactics, simulation, or core curriculum based on student exposure to various core conditions. 2. What does this study attempt to show? This study collected data from three institutions about the number and type of clinical encounters that medical students had during their emergency medicine clerkship. It demonstrated that although most students saw the majority of core conditions, some were rarely encountered. 3. What are the key findings? This study shows that the vast majority of students do not encounter all 10 conditions during actual patient encounters during a 1-month emergency medicine rotation, although most have exposure to at least eight. Certain conditions, most notably cardiac arrest, are far less likely than others to be encountered, and should be taught in a nonclinical setting to meet CDEM recommendations. Exposure seems to be at least somewhat patient volume dependent, so institutions that have lower patient volumes may need to track patient encounters closely and have more nonclinical ways to educate their students. 4. How is patient care impacted? There is no direct effect on patient care.
http://dx.doi.org/10.1016/j.jemermed.2014.04.029
Education MEDICAL STUDENT EDUCATION IN EMERGENCY MEDICINE: DO STUDENTS MEET THE NATIONAL STANDARDS FOR CLINICAL ENCOUNTERS OF SELECTED CORE CONDITIONS? Jennifer Avegno, MD,* Amy Leuthauser, MD,† Joseph Martinez, MD,‡ Melissa Marinelli, MD,§ Gale Osgood, MD,k Robert Satonik, MD,{ and Doug Ander, MD** *Department of Emergency Medicine, LSU-New Orleans, New Orleans, Louisiana, †Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York, ‡Department of Emergency Medicine, University of Maryland, Baltimore, Maryland, §Department of Emergency Medicine, Northwestern University, Chicago, Illinois, kDepartment of Emergency Medicine, University of Missouri-Columbia, Columbia, Missouri, {Synergy Medical, Mount Pleasant, Michigan, and **Department of Emergency Medicine, Emory University, Atlanta, Georgia Reprint Address: Jennifer Avegno, MD, Department of Emergency Medicine, LSU-New Orleans, 1542 Tulane Avenue, New Orleans, LA 70112
, Abstract—Background: Establishing a core curriculum for undergraduate Emergency Medicine (EM) education is crucial to development of the specialty. The Clerkship Directors in Emergency Medicine (CDEM) National Curriculum Task Force recommended that all students in a 4th-year EM clerkship be exposed to 10 emergent clinical conditions. Objectives: To evaluate the feasibility of encountering recommended core conditions in a clinical setting during a 4th-year EM clerkship. Methods: Students from three institutions participated in this ongoing, prospective observation study. Students’ patient logs were collected during 4-week EM clerkships between July 2011 and June 2012. Deidentified logs were reviewed and the number of patient encounters for each of the CDEM-identified emergent conditions was recorded. The percentage of students who saw each of the core complaints was calculated, as was the average number of core complaints seen by each. Results: Data from 130 students at three institutions were captured; 15.4% of students saw all 10 conditions during their rotation, and 76.9% saw at least eight. The average number of conditions seen per student was 8.4 (range of 7.0–8.6). The percentage of students who saw each condition varied, ranging from 100% (chest pain and abdominal pain) to 31% (cardiac arrest). Conclusions: Most students do not encounter all 10 conditions during patient encounters throughout a 4-week EM rotation, although most have exposure to at least eight. Certain conditions are far less likely
than others to be encountered, and may need to be taught in a nonclinical setting. Ó 2014 Elsevier Inc. , Keywords—medical conditions
student;
education;
clinical
INTRODUCTION Clerkship directors and educators aim to provide all students with an educationally meaningful rotation in Emergency Medicine (EM). To do so, student exposure to a sufficient variety of patient complaints is essential. Establishing a core curriculum for undergraduate EM education across the country is crucial to uniform development of the specialty. The Clerkship Directors in Emergency Medicine (CDEM) National Curriculum Task Force recommends that all students in a 4th-year EM clerkship be exposed to 10 emergent clinical conditions (1). These core patient encounters form the basis for a suggested EM curriculum, both clinical and didactic. The Liaison Committee on Medical Education requirements for EM also encourage clerkship directors to provide specific rotation objectives, logs to document exposure, and supplementation with didactics or simulation any topics not encountered clinically (2).
RECEIVED: 12 June 2013; FINAL SUBMISSION RECEIVED: 6 February 2014; ACCEPTED: 28 April 2014 328
Medical Student Education in Emergency Medicine
Previous research has established that a standard student experience can be provided on an EM rotation, given good planning and targeted goals and objectives (3). The use of logbooks to document encounters has been used as a surrogate marker of rotation quality. A study by McGraw and Lord in Canada compared student logbooks of clinical encounters and procedures and compared them to what their faculty considered to be the six most important clinical encounters and five most important procedures. In a 2-week clerkship, several deficiencies in student experiences were found, and these prompted a reappraisal of the program’s objectives (4). A similar study in internal medicine using an electronic logbook to track patient encounters of 18 different training problems published by the Clerkship Directors in Internal Medicine found that 98% of students across six campuses were able to meet prespecified criteria for the number and type of patient encounters (5). None of the previous published research has evaluated students’ likelihood of encountering the CDEM task force’s recommended core conditions in a clinical setting. The purpose of this study was to evaluate whether these recommendations are being met across different clinical and academic sites. We hypothesized that all students would be exposed to all 10 emergent clinical conditions during an EM rotation. If all recommended patient presentations cannot be met via clinical exposure alone, educational techniques may be necessary to ensure a standard experience for every medical student, or modifications of the national syllabus could be considered. METHODS Students from three medical schools participated in this ongoing, prospective observation study. Student data were collected from rotations at three institutions. The rotation at Institution 1 is a mandatory rotation comprised of 14 8-h shifts at an urban, academic emergency department (ED) with a total patient volume of 100,000 visits per year. Both Institutions 2 and 3 send students to rotate in a single urban, academic ED with a patient volume of 70,000 per year, and students work between 9 and 12 12-h shifts. The rotation at Institution 3 is an elective, whereas the rotation at Institution 2 is mandatory. There are EM
329
residents rotating at all three sites. All students were required to complete patient logs during their EM rotation. Rotators entered the chief complaint or diagnosis on each patient encounter using free text. Student instructions on how to enter and complete logs were identical across the three sites, and the logs were standardized across participating institutions. Students were not mandated to see any particular patient or condition, though students at Institution 1 were required to see at least 60 patients per rotation. Patient logs from students collected during their 4week EM clerkships between July 2011 and June 2012 at clinical sites associated with the participating medical schools were pooled and analyzed. At all three sites, the students are mandated to record every patient encounter. Students were not aware of the 10 core conditions during their rotation, and there was no requirement to see any particular complaint. The de-identified logs were reviewed by the investigator at each site and the number of patient encounters for each of the CDEM-identified emergent conditions was recorded. The percentage of students who saw each of the 10 core complaints was calculated. The average number of core complaints seen by each student, as well as the percentage of students who saw each complaint, was also calculated. RESULTS Data were collected from 130 students at three institutions; 15.4% of the students saw all 10 conditions, and 76.9% of students saw eight or more of the conditions during their clerkship (Table 1). The smallest number seen over 4 weeks was five conditions (one student), with five other students seeing only six conditions. The number of students encountering eight or more conditions varied by location. Institution 1 had the largest number of 4-week rotators, and here, the percent of students encountering eight or more conditions was 85.7%, whereas this number was 40% at the other two institutions. Some conditions were encountered more frequently than others (Table 2). All students in the study encountered at least one patient with abdominal pain and one patient with chest pain during their month. Trauma, altered
Table 1. Student Clinical Exposure to Core Complaints
Institution 1 Institution 2 Institution 3 All
# of 4-Week Students
% of Students Encountering All 10 Core Complaints
% of Students Encountering 8 or More Core Complaints
Average # of Core Complaints Seen/Student
Range
105 10 15 130
16.2 10.0 13.3 15.4
85.7 40.0 40.0 76.9
8.6 7.7 7.0 8.4
7–10 6–10 5–9 5–10
330
J. Avegno et al.
Table 2. Frequency of Encountering Core Conditions Condition
Average Number of Times Core Complaint was Encountered
Range
Standard Deviation
% of All Students Seeing Condition
Abdominal pain Altered mental status Cardiac arrest Chest pain Gastrointestinal bleeding Headache Poisoning Respiratory distress Shock Trauma
8.5 4.2 0.5 5.4 1.4 2.0 1.7 4.4 1.2 7.9
2–20 0–16 0–3 1–14 0–5 0–7 0–13 0–11 0–7 0–20
3.7 2.5 0.8 2.6 1.3 1.5 1.8 2.4 1.1 3.8
100 98 32 100 72 87 77 96 75 99
mental status, and respiratory distress were all encountered at least one time by more than 96% of students. Only cardiac arrest was encountered by < 70% of students, regardless of site. Exposure for some conditions did vary widely by location, though most rates were fairly consistent across sites. The number of times each condition was encountered varied greatly as well (Table 2). Abdominal pain and trauma were seen the largest number of times, an average of 8.5 and 7.9 times, respectively. Chest pain, respiratory distress, and altered mental status were seen four to six times per block, on average, with all other conditions averaging fewer than two encounters per rotation. DISCUSSION EM clerkship rotations provide students with a breadth of patient encounters, clinical learning activities, and exposure to management of acute emergencies not always found in other clerkships (1,2,5,6,7). In one study, students on an EM rotation were also significantly more likely to perform an initial evaluation and participate in diagnosis and management decisions than those in an internal medicine (IM) clerkship (8). Other studies have attempted to define a core set of expected patient encounters for medical students in the ED. A 1989 paper using American College of Emergency Physicians curriculum recommendations looked at 32 different categories of patient complaints, and found that only seven were able to reach 80% student penetrance (i.e., only seven categories were seen by at least 80% of all students on the rotation) (9). In our study, six of the 10 core conditions were seen by at least 80% of students. Unsurprisingly, the least-encountered condition was cardiac arrest (only 32% of students), with gastrointestinal bleeding, poisoning, and shock each encountered by roughly three-fourths of students. Similar to other research, 100% of students encountered patients with chest pain and abdominal pain, with variable exposure to other relatively common complaints like shortness of breath, headache, and fever (4).
Other studies have looked at the feasibility of students encountering predetermined core patient presentations while on an EM rotation. One paper examined 10 common chief complaints and found that only 32% of students who were required to see all 10 complaints were actually able to fulfill that requirement (though 79% were able to see nine of 10) (10). In another, only 50% of students documented exposure to at least one patient with each of six core conditions (11). In our study, 15.4% of students encountered all 10 patient presentations, but over 95% saw seven or more. There was some variability based on site in our study: Institution 1 students saw more patients on average per shift, and had a higher percentage of students encountering seven or more core conditions, than did students at the other two institutions. This counters the findings of an IM clerkship performed across sites that found excellent concordance between sites on students’ ability to encounter core presentations (5). However, those were mandated encounters, whereas students in our study were not required to see any particular patient presentation(s). Ensuring a standard experience and clinical exposures for all students, then, may be variable without careful planning and curricular adjustment. Because few clerkships can likely meet targets for clinical exposures, educators should be aware of those presentations least likely to be encountered on shift, and augment these with didactic offerings (9). Students who participated in an EM rotation that included skills laboratories, simulation, tutorials, and other adjunctive learning activities in addition to clinical work valued active experiences (such as Advanced Cardiac Life Support and procedure laboratories) highly (12). Based on our results, a simulated cardiac arrest case would be a high-yield component of an EM rotation. Limitations Our article has several limitations. Investigators did not independently verify the data in the students’ patient logs for accuracy. There was also no specific amount of
Medical Student Education in Emergency Medicine
patient responsibility required for students to log exposure to that condition. It is possible that some students may have logged conditions to which they were exposed in more of a shadowing capacity as opposed to true patient responsibility. However, it would be unusual for students to have significant amounts of responsibility for some of these conditions (e.g., cardiac arrest), and meaningful education can be obtained from patient encounters even without true primary responsibility for those patients. Furthermore, one institution (#1) accounted for the majority of students, and the number of rotators was much smaller at Institutions 2 and 3. This variance may have skewed the data and may decrease the applicability of these data to widespread utility across varied institutions. Institution 1 also has the highest patient volumes (100,000 visits per year vs. 70,000). This raises the possibility that larger patient volumes may lead to exposure to more conditions. If this finding were borne out in future studies, it could have implications for clerkships at smaller institutions. Continued data acquisition and participation by other institutions is planned and may further elucidate whether this is a true finding inherent to EM rotations, or merely an institutional difference. Finally, students were not given specific instructions on how to categorize certain presentations. For example, one student caring for a patient with alcohol intoxication may log this as ‘‘poisoning,’’ whereas another student may log this as ‘‘altered mental status’’ and a third student may log it as both. The lack of standardization of terminology is inherent in the CDEM guidelines. It would be challenging for any set of guidelines to be standardized nationwide. CONCLUSION The vast majority of students do not encounter all 10 conditions in actual patient encounters during a 1-month emergency medicine rotation, although most have expo-
331
sure to at least eight. Certain conditions, most notably cardiac arrest, are far less likely than others to be encountered, and should be taught in a nonclinical setting to meet CDEM recommendations. Clerkship directors should actively monitor their students’ exposure to various emergency conditions and supplement live clinical encounters with other didactic modalities. REFERENCES 1. Manthey DE, Ander DS, Gordon DC, et al. Clerkship Directors in Emergency Medicine (CDEM) Curriculum Revision Group. Emergency medicine clerkship curriculum: update and revision. Acad Emerg Med 2010;17:638–43. 2. 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 U.S. schools of medicine. Acad Emerg Med 2005;12:1003–9. 3. Coates W. An educator’s guide to teaching emergency medicine to medical students. Acad Emerg Med 2004;11:300–6. 4. McGraw R, Lord JA. Clinical activities during a clerkship rotation in Emergency Medicine. J Emerg Med 1997;15:557–62. 5. Ferenchick G, Mohmand A, Mireles J, Solomon D. Using patient encounter logs for mandated clinical encounters in an Internal Medicine clerkship. Teach Learn Med 2009;21:299–304. 6. Russi CS, Hamilton G. A case for emergency medicine in the undergraduate medical school curriculum. Acad Emerg Med 2005;12: 994–8. 7. Burdick WP, Jouriles NJ, D’Onofrio G, Kass LE, Mahoney JF, Restifo KM. Emergency medicine in undergraduate education. Acad Emerg Med 1998;5:1105–10. 8. Johnson GA, Pipas L, Newman-Palmer NB, Brown LH. The emergency medicine rotation: a unique experience for medical students. J Emerg Med 2002;22:307–11. 9. DeLorenzo RA, Mayer D, Geehr EC. Analyzing clinical case distributions to improve an emergency medicine clerkship. Ann Emerg Med 1990;19:746–51. 10. Lampe CJ, Coates WC, Gill AM. Emergency medicine subinternship: does a standard clinical experience improve performance outcomes? Acad Emerg Med 2008;15:82–5. 11. Coates WC, Gendy MS, Gill AM. Emergency medicine subinternship: can we provide a standard clinical experience? Acad Emerg Med 2003;10:1138–41. 12. Yeung M, Beecker J, Marks M, et al. A new emergency medicine clerkship program: students’ perceptions of what works. CJEM 2010;12:212–9.
332
J. Avegno et al.
ARTICLE SUMMARY 1. Why is this topic important? This topic has relevance for emergency medicine clerkships around the county. The results may encourage programs to make modifications to their didactics, simulation, or core curriculum based on student exposure to various core conditions. 2. What does this study attempt to show? This study collected data from three institutions about the number and type of clinical encounters that medical students had during their emergency medicine clerkship. It demonstrated that although most students saw the majority of core conditions, some were rarely encountered. 3. What are the key findings? This study shows that the vast majority of students do not encounter all 10 conditions during actual patient encounters during a 1-month emergency medicine rotation, although most have exposure to at least eight. Certain conditions, most notably cardiac arrest, are far less likely than others to be encountered, and should be taught in a nonclinical setting to meet CDEM recommendations. Exposure seems to be at least somewhat patient volume dependent, so institutions that have lower patient volumes may need to track patient encounters closely and have more nonclinical ways to educate their students. 4. How is patient care impacted? There is no direct effect on patient care.
