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doi: 10.1111/1742-6723.12188

Emergency Medicine Australasia (2014) 26, 69–71

EDUCATION AND TRAINING

Past and future of emergency medicine education and training Victoria Brazil1,2 Department of Emergency Medicine, Gold Coast Health Service, Gold Coast, Queensland, Australia, and 2Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia

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Science fiction movie fans will already be familiar with one possible future for emergency medicine education and training. In the 1999 film The Matrix (Warner Bros.® Entertainment) Keanu Reeves’s character Neo simply connects to a computer via a port in the back of his head and receives a ‘direct download’ of knowledge and skills ranging from martial arts and bullet dodging to languages (enabling him to save the world, obviously). The experience appears briefly painful but incredibly efficient. This might be closer to reality than we think.1,2 The approach taken in The Matrix is the logical extension of medical education and training methods over the past 50 years. As the apprenticeship model used in the preceding 800 years has fallen out of vogue, medical educators have sought to codify and collate their body of knowledge. The training task has been the transmission of this knowledge and skills, with a passing interest in the acquisition of appropriate attitudes and behaviours. Traditional lectures and textbook-based education have been enhanced by advanced curricular design, explicit learning outcomes and psychometrically reliable assessment. Technology, including Social Media, has further improved the effectiveness and efficiency of knowledge transmission. But is this really the right way to acquire the knowledge and skills required for a 21st century emergency physician? Can an efficient ‘direct download’ ever capture the science and art of our practice?

Doctors and other health professionals have been providing care for acutely unwell patients since ancient times. The science and art of clinical practice has predominantly been learned through apprenticeship. The ‘codification’ of medical knowledge for educational purpose started when medical schools first appeared in Italy in the 12th and 13th centuries at Salerno, Bologna and Padua. Although a ‘curriculum review’ is described

at the University of Bologna in the late 16th century,3 learning at these institutions was largely confined to the observation of natural history of disease and from autopsies, as effective treatments were few. Approaches to undergraduate medical education in the USA were shaped by the Flexner reforms in the early 20th century and were largely responsible for the current structure of most Western medical schools, with preclinical learning phases followed by apprenticeship based clinical rotations. ‘Emergency medicine’ does not appear as a distinct curricular area within these medical schools, which were generally structured according to the pathological basis of disease.

Establishment of emergency medicine as a specialty It was the establishment of emergency medicine as a specialty – with dedicated EDs and staff – that required the development of specific training programmes. This occurred in the early 1970s in the USA and similar developments occurred in Australasia, Canada and the UK over the next 10–20 years. Prior to this, staff in Australasian EDs had generally trained in other specialties – surgery, general practice, or medicine – or were pre-vocational doctors. The story of the ACEM training programme for emergency medicine specialists is impressive. A curriculum and training programme was developed with a similar structure, duration and examination system to the other specialist medical colleges. The first Primary Examination (testing the basic sciences of anatomy, pathology, physiology and pharmacology) was first conducted in 1984. The first Fellowship Examination, a six-part clinical exit examination, was held in 1986 with eight successful candidates.4

Victoria Brazil, MBBS, FACEM, MBA, Senior Staff Specialist. © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

V Brazil

Since the establishment of the college training programme, more than 1000 Fellows have graduated. There has been maturation of training processes, curriculum and assessment, and development of robust systems of accreditation of EDs for training. The current Curriculum Revision Project5 promises a significant renewal of curricular objectives and of training and assessment processes. The scope of clinical knowledge and skills required for physicians working in emergency medicine is broad and overlaps with most other specialty areas. Following the general trend in medical education, emergency medicine training now also explicitly includes ‘professional’ domains of learning, including communication, leadership, ethics, teamwork, management and system-based practice. These domains remain underrepresented in teaching activities and in assessment, despite their critical importance in contemporary practice. The education and training of other providers in emergency medicine – nurses, paramedics and advanced practice allied health professionals – has also grown in professional approach and educational practice, including higher qualifications and specialist recognition. Higher education providers offer most of the educational frameworks for these professions, although professional associations also play an important role in nursing and paramedicine. So what does a contemporary emergency medicine training program in 2013 look like? How close are we to a ‘direct download’?

Guided learning in the workplace (the ‘apprenticeship’ model) remains the foundation of emergency medicine training. Trainees have an explicit working role in the ED. ‘Questioning dialogues’, observing, coaching and role modelling are highly effective strategies for workplacebased learning6 and observed every day in all EDs. Accredited EDs also offer structured teaching to support workplace experience. This includes large and small group teaching, journal clubs, procedural skills training and simulation, online learning and a variety of other innovative formats. Most trainees also augment this learning with external resources, including Social Media, FOAM7 and dedicated workshops for skills, such as ultrasound. Assessment drives learning in every educational programme, and the emergency trainees’ focus is often on passing exams. Independent specialist examinations were an early signal of emergency medicine’s credibility as a specialty in Australasia. The adoption of rigorous psychometric analysis of examinations and of work70

place based assessment in emergency medicine are typical of the broader evolution in assessment in medical education. Faculty development and training for clinical supervisors is a surprisingly recent phenomenon. Successful initiatives in this area include Teaching on the Run workshops, graduate certificate programmes in clinical education and college-sponsored activities. Emergency medicine trainee special skills posts in medical education are indicative of a significant profile for education and training within an ED. But are these advances in educational approach enough? Do our ED patients have better outcomes and experiences than they did prior to 1986 when our first Fellows by examination graduated?

Or, as Catherine Lucey MD writes, is medical education ‘part of the problem’ with modern healthcare? ‘. . . although our educational techniques are outstanding, our collective target is wrong. The goal of medical education is not simply to produce physicians. It is to improve the health of our patients and their communities’.8 Lucey calls for training toward a radically different ‘end-point’ for future doctors. Focusing on patient needs, thinking in systems, measuring performance, managing change in complex environments, optimising cooperative work, and innovating to improve quality, safety and satisfaction are critical competencies. Shades of these aspirations can be found in some emergency medicine curricula but much more is needed in explicit development of these skills and in their assessment. Alternatively – are our techniques also wrong? Have we ‘over-codified’ our emergency medicine science and art? Does the competency approach fail to include the tacit elements of our expertise?

Perhaps our future training should draw more from the past and the apprenticeship model? Maybe ‘see one, do one, teach one’ really does facilitate deeper learning, with exposure to those 21st century’s clinical knowledge and skills firmly embedded in the context and culture of the ED. Those science fiction film fans will also be familiar with this alternative future for emergency medicine education and training. In the 1980 Star Wars sequel The Empire Strikes Back (Lucasfilm® Ltd), we follow Luke Skywalker’s struggle as a trainee Jedi Knight. There are no books, no podcasts, no lectures and no assignments – simply a ‘clinical immersion’ on the planet of Dagobah, under the apprenticeship of Yoda, a Jedi Master. The training and the Master are tough. Yoda has high (but clear) expectations. He is prepared to support but not

© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Education and Training

spoon feed and makes it clear that life and death will be outcomes related to Luke’s competence. . . . ‘No. Try not. Do, do. Or do not. There is no try’.9 The future challenges for which this education is preparing him for are not clear – there will not be easy recipes, but there will be best practice, core principles and a need for flexibility and adaptability. Sometimes Luke fails his challenges, sometimes he succeeds. Perhaps most importantly, when Luke leaves planet Dagobah after his training, he is under no delusion that he is finished his education. . . .

2.

Science fiction or fact: instant, ‘matrix’-like learning. livescience.com [Cited 8 Dec 2013.] Available from URL: http:// www.livescience.com/34020-matrix-learning-kung-fu.html

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Lines DA. Reorganizing the curriculum: teaching and learning in the University of Bologna c. 1560–c. 1590*. [Cited 8 Dec 2013.] Available from URL: http://www.2.warwick.ac.uk/fac/arts/ italian/staff/lines/research/hou_xxvi.2.pdf

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ACEM history. Australasian College for Emergency Medicine (ACEM). [Cited 2 Dec 2013.] Available from URL: http:// www.acem.org.au/about.aspx?docId=12

5.

ACEM curriculum revision project. Australasian College for Emergency Medicine. [Cited 7 Dec 2013.] Available from URL: http://www.acem.org.au/education.aspx?docId=1197

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Billett S. Learning in the Workplace: Strategies for Effective Practice. Crows Nest: Allen & Unwin, 2001.

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References

FOAM. Life in the fast lane. [Cited 8 Dec 2013.] Available from URL: http://lifeinthefastlane.com/foam/

8.

Lucey CR. Medical education: part of the problem and part of the solution. JAMA Intern. Med. 2013; 173: 1639–43.

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9.

Star Wars. The Empire Strikes Back script. Lucasfilm Ltd. [Cited 9 Dec 2013.] Available from URL: http://www.blueharvest .net/scoops/esb-script.shtml

Competing interests None declared.

Shibata K, Watanabe T, Sasaki Y, Kawato M. Perceptual learning incepted by decoded fMRI neurofeedback without stimulus presentation. Science 2011; 334: 1413–5.

© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

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Past and future of emergency medicine education and training.

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