p,~_~CIALCONTRIBUTION
The Emergency Medicine Specialty Certification Examination (EMSCE) Jack L. Meatsch, PhD* Ronald L. Krome, MDt Sarah Sprafka, PhD, Charles B. Maclean, PhD§ Maatsch JL, Krome RL, Sprafka S, Maclean CB: The emergency medicine specialty certification examination {EMSCE). JACEP 5:529-534, July 1976. Emergency medicine specialty certification examination; American 8oard of Emergency Medicine; Committee on Board Establishment; Office of Medical Education Research and Development; American College of Emergency Physicians; University Association for Emergency Medical Services, Medical Task Force, emergency medicine board examination. INTRODUCTION If plans proceed on schedule you might be one of the candidates gathered in late fall of 1977 in East Lansing tosit for the first Emergency Medicine Specialty Certification Examination (EMSCE), conducted by the American Board of Emergency Medicine (ABEM). You will take an examination that will test essential medical knowledge and skills in some 22 medical content areas identifiedas the specialty of emergency medicine. The examination will last for two days during which competency will be tested in five ways. O n the first day halfthe group will be administered a battery of multiple choice items, a set of objectively scored, simulated patientmanagement problems and a series of slides, photographs and films requiring visual recognition and inl~rofessorand Project Director,* Assistant Professor and Project Associate,,Office of Medical Education Research and Develop~ent (OMERAD), Michigan State University, East Lansing. 'tMedical Project Director (Chairman of the CertificationTask ~0rce),Director of the Emergency Department at Detroit Genial Hospital and Associate Professor of Surgery, Wayne State University,Detroit. IManager of the A C E P Medical Education Department. ]~e development of E M S C E is supported by the American College of Emergency Physicians and the Emergency Medicine Foundation.
the Address for reprints: Medical Education Department, 3900 ~apital City Blvd., Lansing, MI 48906.
• PJuly 1976
terpretation skills. The other h a l f of the group will be individually scheduled for examiner-administered Simulated Patient Encounters and Simulated Situation Encounters involving the concurrent m a n a g e m e n t of three or more patients. On the second day, the two groups will switch schedules. A few days after the examination, the ABEM will receive computer print-outs of individual Candidate Performance Profiles (CPP) to use in arriving at a decision to certify or not to certify. These C P P will provide the ABEM with s u m m a r y scores in eight to ten major knowledge .and skill categories t h a t cut across the different testing methods. Other profiles will include scores from each of the five different testing methods. Therefore, if a candidate has difficulty with a particular method of testing, it can be t a k e n into account in the final certification decision. The decision to certify will be based on evaluation of each candidate's profile in relation to m i n i m u m acceptable criteria pre-established by the A B E M . Candidates not meeting A B E M standards in one or more areas will be notified of the specific areas of deficiency and scheduled for retesting in those areas. THE DEVELOPMENT PLAN As a firststep in creating the certification examination in emergency medicine, nine nationally recognized testing agencies were invited to submit test development proposals. In February, 1975, after the competitive bidding by five organizations, A C E P entered into contractual arrangements with the Office of Medical Education Research and Development L O M E R A D ) of Michigan State University. O M E R A D was contracted to develop a multi-formated, criterion-referenced certification examination to be ready for its first general administration in late 1977. Summarized below are the major benchmarks of the development plan. March-July 1975
Develop Plans, Make Presentations and Provide ACEP Support in Obtaining Outside Funding. More t h a n 45 Volume 5 Number 7 Page 529
foundations, g o v e r n m e n t a l agencies and p r i v a t e industries were approached and a major proposal was submitted to H E W t h a t was subsequently turned down. It was resubmitted after substantial changes in March, 1976.
July-December 1975 Specify Content Domains of Emergency Medicine. A 25-member Medical T a s k Force (all m e m b e r s of A C E P and/or UA/EMS) was organized into five committees to define a n d d o c u m e n t the e s s e n t i a l content and skills of e m e r g e n c y medicine upon which candidates will be tested for certification. O M E R A D conducted workshops to facilit a t e this process, a product of which will be a d o c u m e n t t h a t will be a v a i l a b l e to A C E P m e m b e r s a n d for t e s t p r e p a r a t i o n . The d o c u m e n t will also serve as a guide to e m e r g e n c y medicine residency directors and c o n t i n u i n g medical education (CME) p r o g r a m directors. January-July 1976 Develop Test Items and Detailed Simulations. T h i s period b e g a n w i t h r e v i e w i n g and e d i t i n g of the e m e r gency medicine content sheets written by Medical T a s k Force members, assigning item quotas to content a r e a s and a w o r k s h o p for t e s t i t e m a n d s i m u l a t i o n development. D u r i n g this period, which we are in now, i t e m s will be g e n e r a t e d and reviewed by Medical Task Force members. August 1976 A B E M Approves Test Forms, Scoring System and Validation Plans. July-December 1976 Produce Items and Simulations. O M E R A D will complete d e v e l o p m e n t of all t e s t items, films and other simulations. P r o t o t y p e s i m u l a t i o n s will undergo developmental t e s t i n g and final approval by the medical author, who designed the o r i g i n a l test i t e m or simulation. January-July 1977 Validate all Test Materials, Assemble First Examination and Certify Potential Examiners. A t least four differe n t groups of p h y s i c i a n s a n d medical students will t a k e a prototype e x a m i n a t i o n composed of all items and s i m u l a tions developed to date. Scores will be compared to see if the t e s t s e p a r a t e s p r a c t i c i n g e m e r g e n c y physicians from others. The best items and s i m u l a t i o n s will be r e t a i n e d for inclusion in the first e x a m i n a t i o n . July-December 1977 Train Examiners, Administer, Score and Certify First Group of Eligible Candidates. As of this publication, t h e medical content h a s been reviewed by the A u d i t Comm i t t e e , c o m p o s e d of t h e m e d i c a l project d i r e c t o r a n d c h a i r m e n of t h e five M e d i c a l T a s k Force c o m m i t t e e s . The I t e m D e v e l o p m e n t W o r k s h o p was held J a n u a r y 15 to 16, 1976. T a s k Force m e m b e r s a r e now d e v e l o p i n g m u l t i p l e choice items and case scenarios t h a t will l a t e r be converted into the v a r i o u s s i m u l a t i o n formats. DEVELOPMENT ORGANIZATION T h e r e are over 30 A C E P and UA/EMS m e m b e r s a n d H e a d q u a r t e r s staff, and a t l e a s t 16 OMERAD faculty a n d
Page 530 Volume 5 Number 7
g r a d u a t e a s s i s t a n t s , directly involved in the development of t h e c e r t i f i c a t i o n e x a m i n a t i o n . This core group bag been, or will be, periodically a u g m e n t e d by an almost equal n u m b e r of medical content reviewers, consultaats and m e d i a production technicians. This p r o g r a m repre. sents the l a r g e s t single d e v e l o p m e n t effort for both ACI~I~ and O M E R A D for the n e x t two years. The basic organiza. tion c h a r t of this t e a m effort is o u t l i n e d in F i g u r e 1.
EMSCE
]
The proposed E m e r g e n c y Medicine S p e c i a l t y Certifica. t i o n E x a m i n a t i o n ( E M S C E ) is a m u l t i - f o r m a t e d , criterion-referenced certification e x a m i n a t i o n . It is subtly different from the c o n v e n t i o n a l norm-referenced exam. inations used by others for licensing a n d medical spe. c i a l t y c e r t i f i c a t i o n . T h e a d v a n t a g e s of c r i t e r i o a . r e f e r e n c e d t e s t s i n f l u e n c e d A C E P to choose t h i s ap. proach.
Why a Criterion Referenced Certification Examination? On the surface, a norm-referenced t e s t a n d a criterion. referenced t e s t look alike and m a y use t h e s a m e formats. However, the test items for each are developed with dif. ferent s t r a t e g i e s and t h e y have a different scoring philos. ophy. In fact, the criterion-referenced a p p r o a c h was de. veloped to avoid the i n h e r e n t problems of the conven. tional norm-referenced test. These problems become quite serious when a norm-referenced test is used in medical certifying a n d licensing e x a m i n a t i o n s t h a t involve corn. plex professional behaviors. P r a c t i c a l l y all c u r r e n t board e x a m i n a t i o n s are normreferenced. Norm-referenced m e a n s c a n d i d a t e s compete with each other for h i g h scores. C a n d i d a t e s a r e ~graded on t h e curve" produced b y . o t h e r candidates. Therefore, some percentage of the candidates taking the exam must fail in order to give a n y m e a n i n g to p a s s i n g a normreferenced certification e x a m i n a t i o n . In m o s t board exa m i n a t i o n s , the cut-off point is set so t h a t 15% to 20% of all c a n d i d a t e s fail. If everyone scored v e r y high, t h e n the test questions would be considered too e a s y a n d revised, or t h e c u t - o f f p o i n t w o u l d be m o v e d up. In a normreferenced e x a m i n a t i o n t h e r e a r e no i n d e p e n d e n t standards by which to j u d g e a c c e p t a b l e professional competence, only competition with peers for h i g h e r scores. Now, consider t h e criterion-referenced a p p r o a c h to certification. This approach differs in two very important ways - - in the method of selecting test i t e m s and in the m e t h o d of i n t e r p r e t i n g t e s t scores. To e x p l a i n these diff e r e n c e s , w e ' l l c o m p a r e t h e a p p r o a c h e s of a normreferenced t e s t a n d a criterion-referenced t e s t with respect to test i t e m development, to test scoring and t h e n to certification decision m a k i n g .
TEST ITEM DEVELOPMENT In a norm-referenced test, the objective is to randomly s a m p l e broad a r e a s of medical knowledge w i t h test items t h a t each produce a b o u t a 50% f a i l u r e r a t e . T h i s imm e d i a t e l y r e s t r i c t s the items' content to the difficult and a b s t r a c t , i n f r e q u e n t l y used, e a s i l y forgotten, or highly specific m e d i c a l k n o w l e d g e . C a n d i d a t e s t h e n compete
July 1976 J ~ P
f
ORGANIZATION OF THE EXAMINATION DEVELOPMENT TEAM
American Board of Emergency Medicine (ABEM)
ACEP Committee on Board Establishment (COBE)
Planning, Monitoring and Documentation Group (PMD)
Contract Executive Committee (CEC)
Medical Project Director Ronald L. Krome, MD
OMERAD Project Director Jack L. Maatsch, PhD Audit Committee
| Manager, ACEP Medical Education Department Charles B. Maclean, PhD
MEDICAL TASK FORCE Chairmen
OMERAD Test Development Team
I
C. C. Roussi, MD
Medicine (6 members)
George Podgorny, MD
Surgery/Trauma (7 members)
Ronald P. White, MD
Cardiorespiratory (5 members)
A. L. Jenkins, MD Karl G. Mangold, MD
EMS Administration Systems (4 members) Physician/Patient and Legal/Ethical (5 members)
Multiple Choice Battery Patient Management Problems Stimulus Films and Slides Simulated Patient Encounters Validation and Scoring Systems
ABEM: The American Board of Emergency Medicine will be incorporated during 1976. It will function as the independent certifying body for the specialty of emergency.medicine. Only ABEM can determine eligibility requirements and examination administration and scoring procedures. COBE: The Committee on Board Establishment is charged with securing the necessary recognition for the specialty of emergency medicine and overseeing the examination development process. COBE reports to the Board of Directors of ACEP and Will be dissolved when ABEM has its first meeting. CEC: The Contract Executive Committee is a seven-member body composed of ACEP and OMERAD administrative personnel. Jtdecides questions of contract specifications, products, personnel, task performance, disputes, appeals and termination.
PMD:The Planning; Monitoring and Documentation group is composed of ACEP members and OMERAD professional staff not directly involved in developing the examination. They formulate, resolve and/or document methodological and substantive Policy issues that arise during the development of the examination. AUDIT COMMITTEE: The Audit Committee is composed of the five chairmen of the Medical Task Force Committees and the medical project director.
~ig. 1. Organization chart of team developing the certification examination in emergency medicine. J~)
July 1976
V o l u m e 5 N u m b e r 7 Page 531
GUIDELINES FOR THE SELECTION OF CONTENT TO BE TESTED General Guidelines for all Item Types Remember this is a criterion-referenced test. You are n o t trying to select deliberately hard or tricky test items. Try to select: •
frequently encountered cases and problems
•
necessary knowledge (clinical or basic science) that must be r e m e m b e r e d at all times during practice
•
problems and knowledge related to time-sensitive decisions and treatments (where candidate would not have time to look up necessary information)
•
problems and knowledge related to life-threatening situations
•
problems or knowledge that is common to all ED settings (Not geographic or location-specific laws, diseases, treatments, drugs, etc.) Scenario Selection Guidelines (All Simulation Formats) Try to select cases that: •
require differential diagnosis
•
incorporate commonly associated problems
•
include legal-ethical, psychiatric and/or physician-patient relation problems
•
are frequently encountered and central to the content area assigned
•
can be rapidly and appropriately disposed of in the ED
•
have significantly different outcomes depending on diagnosis and treatment
• do not require the use of special equipment or expensive, bulky or nonexistent simulators Multiple Choice Selection Guidelines Try to select: •
frequently used general rules or principles
•
knowledge that is the end-product of other related knowledges. (If the candidate knows this, then he/she must also know those other things)
•
absolutely essential knowledge for proper ED practice. (Avoid isolated facts, abstract, remotely related basic science knowledge, rare diseases, etc.)
•
specific applications or decision points having unambiguous and generally agreed upon correct and incorrect alternatives
•
content that does not require an elaborate, lengthy description of preconditions or qualifications in ordering tests
Slide or Photograph Selection Guidelines Try to select: •
visual materials that test general interpretative skills
•
visual materials that commonly require immediate interpretation and use in the ED
•
visual materials that, when projected on a large screen, knowledgeable candidates can clearly see and easily interpret.
F i g . 2. Guidelines for the selection of test items being followed by members of the Medical Task Force. with each other to see who knows the most of this t y p e of information. In contrast, a criterion-referenced test a t t e m p t s to rat i o n a l l y s a m p l e essential k n o w l e d g e in p r e d e t e r m i n e d specific a r e a s of medical knowledge. The m i n i m u m acceptable performance is d e t e r m i n e d in advance by the c a n d i d a t e ' s peers. All c a n d i d a t e s t a k i n g the test can pass if t h e y m e e t p r e d e t e r m i n e d board s t a n d a r d s , or all can fail if t h e y don't. C a n d i d a t e s compete w i t h previously set s t a n d a r d s , not w i t h each other. The specific k n o w l e d g e and skill a r e a s t h a t will be t e s t e d by t h e E M S C E h a v e been i d e n t i f i e d and docuPage 532 Volume 5 Number 7
m e n t e d by the Medical Task Force and reviewed by the A u d i t C o m m i t t e e . This d o c u m e n t will be a v a i l a b l e to c a n d i d a t e s and A C E P m e m b e r s before t a k i n g the exar~' i n a t i o n . C u r r e n t l y , t h e T a s k Force is g e n e r a t i n g test items, from the p r e d e t e r m i n e d content areas, in several different formats following g u i d e l i n e s for the selection of test items (Figure 2). A criterion-referenced test will be totally composed of items t h a t m e a s u r e e s s e n t i a l a n d f r e q u e n t l y used knowl" edge in e m e r g e n c y medicine w i t h o u t r e g a r d to how easy or h a r d t h e question is. At first glance t h e t e s t may a p p e a r to be easy compared to a norm-referenced test. However, c a n d i d a t e s will be expected to respond correct' July 1976 ~ ] ~ P
ly to a very h i g h p e r c e n t a g e of these items since t h e y #e directly r e l a t e d to essential p a t i e n t care. As a consequence, o b t a i n i n g c e r t i f i c a t i o n m a y or m a y n o t be ~ s i e r w i t h a c r i t e r i o n - r e f e r e n c e d t e s t d e p e n d i n g on the s t a n d a r d s set in advance by ABEM. This leads us to a comparison of t h e scoring and certification decisions of the two t y p e s of tests.
TEST SCORING The p r i m a r y o v e r r i d i n g objective of a norm-referenced certification e x a m i n a t i o n is to spread out c a n d i d a t e scores. The g r e a t e r the spread, the better, especially at the lower end of the scale where the cut-off point for failure is established. The l a r g e r the gap between the scores of the bottom 15% to 20% a n d the rest of the scores, the less e m b a r r a s s i n g it is to r a t i o n a l i z e the selection of t h e cut-off point and the easier it is to e x p l a i n to failed candidates w h y t h e y a r e less competent t h a n other candidates who scored a few points h i g h e r and were certified. ,Remember, this cut-off point is a s t a t i s t i c a l l y d e t e r m i n e d score b~sed on group scores. This "pass" score can v a r y with each group of c a n d i d a t e s or each new version of the test. T h e r e is no r e f e r e n c e to e x t e r n a l l y e s t a b l i s h e d standards of performance n e c e s s a r y to c o m p e t e n t l y practice the specialty. In contrast, t h e criterion-referenced test is scored according to s t a n d a r d s (criteria) of acceptable performance in specific competency a r e a s developed when the t e s t is developed. E a c h c a n d i d a t e is j u d g e d independently, not according t ° how other c a n d i d a t e s t a k i n g the test at t h e same t i m e perform. CERTIFICATION DECISION MAKING The t e s t scores p r e s e n t e d to the Board are different for the two a p p r o a c h e s to t e s t i n g and so is the Board's role in Raking t h e decision to certify a c a n d i d a t e . For normreferenced tests, the Board d e t e r m i n e s or approves a failure p e r c e n t a g e b a s e d on group scores. Clerks or computers a p p l y the necessary statistics to produce t h a t perI'centage a n d notify c a n d i d a t e s of the outcome. On t h e o t h e r hand, the proposed criterion-referenced test will provide the A B E M w i t h a profile of scores on each candidate. The c o m p o n e n t scores or competencies t h a t will m a k e up t h e c a n d i d a t e ' s profile have not y e t been determined. However, t h e y will reflect the c a n d i d a t e ' s Iknowledge a n d s k i l l s in 22"specific m e d i c a l c o n t e n t bcategories. The p e r c e n t a g e of items t h a t will be allocated to each of the 22 different medical c o n t e n t categories COmposing the specialty, e m e r g e n c y medicine, has been approximately d e t e r m i n e d (Table). The categories were adapted from those produced by the Conference on Education of the P h y s i c i a n in E m e r g e n c y Medical Care. 1 !Percentage a l l o c a t i o n s a r e b a s e d on a q u e s t i o n n a i r e ~ubmitted to a s a m p l e of 135 A C E P m e m b e r s a s k i n g them to d e t e r m i n e t h e r e l a t i v e i m p o r t a n c e of e a c h Category for certification testing. Each c a n d i d a t e ' s profile of scores will be compared w i t h ~re-established s t a n d a r d s for each component score or COmpetency. E x t e n s i v e v a l i d a t i o n t e s t i n g of d i f f e r e n t groups of p h y s i c i a n s a n d medical s t u d e n t s will help t h e l~oard e s t a b l i s h these s t a n d a r d s before the first e x a m i n a tion. A decision to certify or not to certify will r e q u i r e
~P
July 1976
Table PERCENTAGE OF TEST ITEMS ALLOCATED TO MEDICAL CONTENT CATEGORIES
% 13 7 7
Category Cardiovascular disorders (traumatic and nontraumatic) Abdominal disorders
7 7 7 7
Ear, nose, throat, head and neck injuries (traumatic and nontraumatic) Pulmonary disorders Skeletal injuries Traumatic disorders Urogenital disorders
6
Infancy and childhood disorders
5
Metabolic, allergic and toxicologic disorders Fluid and electrolyte problems Neurological disorders
4 4 3
Behaviorial disorders
3 3
Burn and cold exposure Critical infections
3
3
Emergency medical services system (including disaster planning and management) Eye disorders (traumatic and nontraumatic) Legal-ethical
2 2
Blood disorders Physician-patient skills
2 1 1
Emergency department a~dministration Dental emergencies Integumental disorders
3
100% j u d g m e n t s of v a r y i n g complexity. Obviously, candidates c l e a r l y m e e t i n g all s t a n d a r d s in each competency will r o u t i n e l y be certified a n d those failing to m e e t s t a n d a r d s in most a r e a s will r o u t i n e l y not be certified. It is the g r a y a r e a where j u d g m e n t s become more complex. For example, a c a n d i d a t e m a y m a r g i n a l l y fail to m e e t one or more s t a n d a r d s b u t excell in other r e l a t e d areas. R e m e m b e r the t e s t scores are estimates of how much the c a n d i d a t e s rea l l y know. In a n o t h e r case, a c a n d i d a t e ' s performance m a y be m a r k e d l y different on one test format, eg, multiple choice questions, in comparison to the o t h e r formats. T h i s " h a n g up" m a y a r t i f i c i a l l y l o w e r a score below s t a n d a r d s in several competencies. F i n a l l y , a candidate m a y m a r g i n a l l y pass or fail in all competencies b u t with the m a r g i n a l failures in r e l a t i v e l y less i m p o r t a n t competencies. These and still other special cases r e q u i r e complicated professional j u d g m e n t s by ABEM. The overall j u d g m e n t
Volume 5 Number 7 Page 533
process is more complex, less objective and, as a result, more e x p e n s i v e t h a n in n o r m - r e f e r e n c e d tests b u t the final decision to certify is both i n d i v i d u a l i z e d a n d rational. Since c a n d i d a t e s a r e competing with s t a n d a r d s , it is e n t i r e l y possible t h a t t h e Board will notify failing cand i d a t e s of t h e i r specific a r e a s of deficiency a n d t h e n l a t e r r e t e s t those c a n d i d a t e s in specific deficiencies. These decisions have not been m a d e by the ABEM as yet b u t t h e y are consistent w i t h the criterion-referenced test s t r a t e g y chosen by ACEP. SUMMARY
The concept b e h i n d t h e p r o j e c t e d E M S C E , t h e development schedule, its c u r r e n t s t a t u s and the organization of the t e a m developing the e x a m i n a t i o n have been presented. The norm-referenced test s t r a t e g y commonly used in medical certification e x a m i n a t i o n s was compared with the criterion-referenced test s t r a t e g y being used in the d e v e l o p m e n t of the EMSCE. The two t e s t s t r a t e g i e s
Page 534 Volume 5 Number 7
influence the medical content selected for test items~ well as t h e method of e v a l u a t i n g professional compete~ cies for p u r p o s e s of c e r t i f i c a t i o n . W h i l e criteri~J referenced tests are more exp6nsive to develop, we feelil t h e long r u n t h e y w i l l be a d o p t e d by m o s t medici specialties as the most r a t i o n a l approach to certificati~ a n d recertification. The objective of this article is best s u m m a r i z e d byt spontaneous r e m a r k made by a m e m b e r of the Medie~J T a s k Force d u r i n g the r e c e n t I t e m D e v e l o p m e n t W0r~J shop. "My God,, he stated, This r e a l l y is a different ty~ of t e s t t h a n we ve ever taken! How will we ever explaiI to c a n d i d a t e s t h a t it s not j u s t . a lot of t r i c k questions?fl REFERENCES 1. Report on the Conference on Education of the Physicia~ i~l Emergency Medical Care, Council on Medical Education, AM~']
1973.
July 1976 J ~
sPECIAL CONTRIBUTION
The ED Record
Friend or Foe
James E. George, MD, JD Woodbury, New Jersey
JACEP 5:535540, July 1976. emergency department record, medicolegal implications. George JE: The ED record - - friend or foe.
INTRODUCTION
Today, for m a n y reasons, e m e r g e n c y d e p a r t m e n t (ED) and other hospital record requirements are much more stringent t h a n even a few y e a r s ago. S t a t e laws have been passed in some j u r i s d i c t i o n s m a n d a t i n g stricter ED record keeping. F e d e r a l l y r e l a t e d h e a l t h care p r o g r a m s , such as M e d i c a r e a n d M e d i c a i d , o p e r a t e u n d e r r e g u lations d e m a n d i n g more complete ED record documentation. A c c r e d i t i n g o r g a n i z a t i o n s , s u c h as t h e J o i n t Commission on A c c r e d i t a t i o n of Hospitals (JCAH), h a v e established some of the most comprehensive ED record procedures. The i n s u r a n c e i n d u s t r y w i t h its need to d e t e r m i n e coverag e has e x e r t e d g r e a t practical force in developing more d e t a i l e d medical records. The p a s s a g e of t h e PSRO law has t h r o w n into s h a r p focus t h e federal g o v e r n m e n t ' s desire to cod,ify h e a l t h care s t a n d a r d s . C e r t a i n forensic medical events such as rape, b a t t e r e d children and intoxicated drivers have emphasized meticulous ED r e c o r d k e e p i n g as t h e only m e a n s by which justice can be accomplished. F i n a l l y , the t r u e significance of an a d e q u a t e ED record has been d r i v e n home to t h e e m e r g e n c y p h y s i c i a n b y the plague of medical m a l p r a c t i c e litigation s u r r o u n d i n g t h e practice of m o d e r n medicine. The ED record is critical to a successful m a l p r a c t i c e defense. It is the first, best and sometimes only chance for the e m e r g e n c y physician to withstand a m a l p r a c t i c e lawsuit, Dr. George is a practicing emergency physician at the Underrood-Memorial Hospital in Woodbury, New Jersey. He is also a lawyer and editor of the Emergency Nurse Legal Bulletin and the Emergency Physician Legal -Bulletin. Further information about the Bulletins can be obtained from MED/LAW Publishers, Inc, PO Box 293, Westville, Nev~ Jersey 08093. This article was first published in the Emergency Physician " Legal Bulletin, Volume 1, Number 3, Summer 1975, copyright 1976 MED/LAW Publishers, Inc, reprinted with permission.
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July 1976
The following discussion a t t e m p t s to f a m i l i a r i z e t h e e m e r g e n c y physician with the medicolegal ramifications of t h e ED record. Statutes and Regulations
Several s t a t e s including K a n s a s , Colorado, Massachusetts and New York have p a s s e d s t a t u t e s and r e g u l a tions r e q u i r i n g t h a t c e r t a i n d e t a i l s a p p e a r in the ED record i n c l u d i n g p a t i e n t identification, test r e s u l t s (eg, lab, x-ray, etc), diagnosis, t r e a t m e n t and disposition of the case and the s i g n a t u r e of t h e t r e a t i n g physician. Some states, such as Colorado, even r e q u i r e t h a t the t r e a t i n g p h y s i c i a n be responsible for t h e a d e q u a t e completion of t h e E D record. F i n a l l y , some provision is made for storage of such records in a record room facility. The U S D e p a r t m e n t of H e a l t h , E d u c a t i o n and Welfare has f o r m u l a t e d r e g u l a t i o n s or s t a n d a r d s as conditions of hospital E D ' p a r t i c i p a t i o n in Medicare and Medicaid. It is g e n e r a l l y r e q u i r e d t h a t a d e q u a t e records, c o n t a i n i n g the i n f o r m a t i o n a l r e a d y listed, be k e p t on e v e r y p a t i e n t t r e a t e d in the ED. It is also r e q u i r e d t h a t ED records be organized by a medical record l i b r a r i a n or equivalent, int e g r a t e d w i t h i n p a t i e n t and o u t p a t i e n t records when app r o p r i a t e and k e p t as long as r e q u i r e d by state s t a t u t e s of l i m i t a t i o n s , sometimes up to 10 years. Recordsmanship
Most e m e r g e n c y physicians view the ED record as an u n a v o i d a b l e burden, to be gotten rid of as quickly as possible. In fact, t h e ED record is a medicolegal challenge of Lhe h i g h e s t priority. The ED record should be constructed by the e m e r g e n c y physician so t h a t it presents a n accurate, logical a n d complete story as d e t e r m i n e d by the facts. The issues of abbreviations and legibility remain s o m e w h a t clouded. It is c e r t a i n l y a p p r o p r i a t e for t h e e m e r g e n c y physician to use accepted medical abbreviations in the ED record. It is not so c e r t a i n w h e t h e r these a b b r e v i a t i o n s are a p p r o p r i a t e w h e n w r i t i n g the diagnosis b e c a u s e n o n m e d i c a l p e r s o n n e l , such as r e c o r d r o o m clerks, b i l l i n g clerks, p r i v a t e a n d g o v e r n m e n t a l insurance clerks, m u s t r e a d and deal with the diagnosis as p a r t of t h e i r job. This issue has been resolved in i n p a t i e n t
Volume 5 Number 7 Page 535
The Emergency Medicine Specialty Certification Examination (EMSCE) Jack L. Meatsch, PhD* Ronald L. Krome, MDt Sarah Sprafka, PhD, Charles B. Maclean, PhD§ Maatsch JL, Krome RL, Sprafka S, Maclean CB: The emergency medicine specialty certification examination {EMSCE). JACEP 5:529-534, July 1976. Emergency medicine specialty certification examination; American 8oard of Emergency Medicine; Committee on Board Establishment; Office of Medical Education Research and Development; American College of Emergency Physicians; University Association for Emergency Medical Services, Medical Task Force, emergency medicine board examination. INTRODUCTION If plans proceed on schedule you might be one of the candidates gathered in late fall of 1977 in East Lansing tosit for the first Emergency Medicine Specialty Certification Examination (EMSCE), conducted by the American Board of Emergency Medicine (ABEM). You will take an examination that will test essential medical knowledge and skills in some 22 medical content areas identifiedas the specialty of emergency medicine. The examination will last for two days during which competency will be tested in five ways. O n the first day halfthe group will be administered a battery of multiple choice items, a set of objectively scored, simulated patientmanagement problems and a series of slides, photographs and films requiring visual recognition and inl~rofessorand Project Director,* Assistant Professor and Project Associate,,Office of Medical Education Research and Develop~ent (OMERAD), Michigan State University, East Lansing. 'tMedical Project Director (Chairman of the CertificationTask ~0rce),Director of the Emergency Department at Detroit Genial Hospital and Associate Professor of Surgery, Wayne State University,Detroit. IManager of the A C E P Medical Education Department. ]~e development of E M S C E is supported by the American College of Emergency Physicians and the Emergency Medicine Foundation.
the Address for reprints: Medical Education Department, 3900 ~apital City Blvd., Lansing, MI 48906.
• PJuly 1976
terpretation skills. The other h a l f of the group will be individually scheduled for examiner-administered Simulated Patient Encounters and Simulated Situation Encounters involving the concurrent m a n a g e m e n t of three or more patients. On the second day, the two groups will switch schedules. A few days after the examination, the ABEM will receive computer print-outs of individual Candidate Performance Profiles (CPP) to use in arriving at a decision to certify or not to certify. These C P P will provide the ABEM with s u m m a r y scores in eight to ten major knowledge .and skill categories t h a t cut across the different testing methods. Other profiles will include scores from each of the five different testing methods. Therefore, if a candidate has difficulty with a particular method of testing, it can be t a k e n into account in the final certification decision. The decision to certify will be based on evaluation of each candidate's profile in relation to m i n i m u m acceptable criteria pre-established by the A B E M . Candidates not meeting A B E M standards in one or more areas will be notified of the specific areas of deficiency and scheduled for retesting in those areas. THE DEVELOPMENT PLAN As a firststep in creating the certification examination in emergency medicine, nine nationally recognized testing agencies were invited to submit test development proposals. In February, 1975, after the competitive bidding by five organizations, A C E P entered into contractual arrangements with the Office of Medical Education Research and Development L O M E R A D ) of Michigan State University. O M E R A D was contracted to develop a multi-formated, criterion-referenced certification examination to be ready for its first general administration in late 1977. Summarized below are the major benchmarks of the development plan. March-July 1975
Develop Plans, Make Presentations and Provide ACEP Support in Obtaining Outside Funding. More t h a n 45 Volume 5 Number 7 Page 529
foundations, g o v e r n m e n t a l agencies and p r i v a t e industries were approached and a major proposal was submitted to H E W t h a t was subsequently turned down. It was resubmitted after substantial changes in March, 1976.
July-December 1975 Specify Content Domains of Emergency Medicine. A 25-member Medical T a s k Force (all m e m b e r s of A C E P and/or UA/EMS) was organized into five committees to define a n d d o c u m e n t the e s s e n t i a l content and skills of e m e r g e n c y medicine upon which candidates will be tested for certification. O M E R A D conducted workshops to facilit a t e this process, a product of which will be a d o c u m e n t t h a t will be a v a i l a b l e to A C E P m e m b e r s a n d for t e s t p r e p a r a t i o n . The d o c u m e n t will also serve as a guide to e m e r g e n c y medicine residency directors and c o n t i n u i n g medical education (CME) p r o g r a m directors. January-July 1976 Develop Test Items and Detailed Simulations. T h i s period b e g a n w i t h r e v i e w i n g and e d i t i n g of the e m e r gency medicine content sheets written by Medical T a s k Force members, assigning item quotas to content a r e a s and a w o r k s h o p for t e s t i t e m a n d s i m u l a t i o n development. D u r i n g this period, which we are in now, i t e m s will be g e n e r a t e d and reviewed by Medical Task Force members. August 1976 A B E M Approves Test Forms, Scoring System and Validation Plans. July-December 1976 Produce Items and Simulations. O M E R A D will complete d e v e l o p m e n t of all t e s t items, films and other simulations. P r o t o t y p e s i m u l a t i o n s will undergo developmental t e s t i n g and final approval by the medical author, who designed the o r i g i n a l test i t e m or simulation. January-July 1977 Validate all Test Materials, Assemble First Examination and Certify Potential Examiners. A t least four differe n t groups of p h y s i c i a n s a n d medical students will t a k e a prototype e x a m i n a t i o n composed of all items and s i m u l a tions developed to date. Scores will be compared to see if the t e s t s e p a r a t e s p r a c t i c i n g e m e r g e n c y physicians from others. The best items and s i m u l a t i o n s will be r e t a i n e d for inclusion in the first e x a m i n a t i o n . July-December 1977 Train Examiners, Administer, Score and Certify First Group of Eligible Candidates. As of this publication, t h e medical content h a s been reviewed by the A u d i t Comm i t t e e , c o m p o s e d of t h e m e d i c a l project d i r e c t o r a n d c h a i r m e n of t h e five M e d i c a l T a s k Force c o m m i t t e e s . The I t e m D e v e l o p m e n t W o r k s h o p was held J a n u a r y 15 to 16, 1976. T a s k Force m e m b e r s a r e now d e v e l o p i n g m u l t i p l e choice items and case scenarios t h a t will l a t e r be converted into the v a r i o u s s i m u l a t i o n formats. DEVELOPMENT ORGANIZATION T h e r e are over 30 A C E P and UA/EMS m e m b e r s a n d H e a d q u a r t e r s staff, and a t l e a s t 16 OMERAD faculty a n d
Page 530 Volume 5 Number 7
g r a d u a t e a s s i s t a n t s , directly involved in the development of t h e c e r t i f i c a t i o n e x a m i n a t i o n . This core group bag been, or will be, periodically a u g m e n t e d by an almost equal n u m b e r of medical content reviewers, consultaats and m e d i a production technicians. This p r o g r a m repre. sents the l a r g e s t single d e v e l o p m e n t effort for both ACI~I~ and O M E R A D for the n e x t two years. The basic organiza. tion c h a r t of this t e a m effort is o u t l i n e d in F i g u r e 1.
EMSCE
]
The proposed E m e r g e n c y Medicine S p e c i a l t y Certifica. t i o n E x a m i n a t i o n ( E M S C E ) is a m u l t i - f o r m a t e d , criterion-referenced certification e x a m i n a t i o n . It is subtly different from the c o n v e n t i o n a l norm-referenced exam. inations used by others for licensing a n d medical spe. c i a l t y c e r t i f i c a t i o n . T h e a d v a n t a g e s of c r i t e r i o a . r e f e r e n c e d t e s t s i n f l u e n c e d A C E P to choose t h i s ap. proach.
Why a Criterion Referenced Certification Examination? On the surface, a norm-referenced t e s t a n d a criterion. referenced t e s t look alike and m a y use t h e s a m e formats. However, the test items for each are developed with dif. ferent s t r a t e g i e s and t h e y have a different scoring philos. ophy. In fact, the criterion-referenced a p p r o a c h was de. veloped to avoid the i n h e r e n t problems of the conven. tional norm-referenced test. These problems become quite serious when a norm-referenced test is used in medical certifying a n d licensing e x a m i n a t i o n s t h a t involve corn. plex professional behaviors. P r a c t i c a l l y all c u r r e n t board e x a m i n a t i o n s are normreferenced. Norm-referenced m e a n s c a n d i d a t e s compete with each other for h i g h scores. C a n d i d a t e s a r e ~graded on t h e curve" produced b y . o t h e r candidates. Therefore, some percentage of the candidates taking the exam must fail in order to give a n y m e a n i n g to p a s s i n g a normreferenced certification e x a m i n a t i o n . In m o s t board exa m i n a t i o n s , the cut-off point is set so t h a t 15% to 20% of all c a n d i d a t e s fail. If everyone scored v e r y high, t h e n the test questions would be considered too e a s y a n d revised, or t h e c u t - o f f p o i n t w o u l d be m o v e d up. In a normreferenced e x a m i n a t i o n t h e r e a r e no i n d e p e n d e n t standards by which to j u d g e a c c e p t a b l e professional competence, only competition with peers for h i g h e r scores. Now, consider t h e criterion-referenced a p p r o a c h to certification. This approach differs in two very important ways - - in the method of selecting test i t e m s and in the m e t h o d of i n t e r p r e t i n g t e s t scores. To e x p l a i n these diff e r e n c e s , w e ' l l c o m p a r e t h e a p p r o a c h e s of a normreferenced t e s t a n d a criterion-referenced t e s t with respect to test i t e m development, to test scoring and t h e n to certification decision m a k i n g .
TEST ITEM DEVELOPMENT In a norm-referenced test, the objective is to randomly s a m p l e broad a r e a s of medical knowledge w i t h test items t h a t each produce a b o u t a 50% f a i l u r e r a t e . T h i s imm e d i a t e l y r e s t r i c t s the items' content to the difficult and a b s t r a c t , i n f r e q u e n t l y used, e a s i l y forgotten, or highly specific m e d i c a l k n o w l e d g e . C a n d i d a t e s t h e n compete
July 1976 J ~ P
f
ORGANIZATION OF THE EXAMINATION DEVELOPMENT TEAM
American Board of Emergency Medicine (ABEM)
ACEP Committee on Board Establishment (COBE)
Planning, Monitoring and Documentation Group (PMD)
Contract Executive Committee (CEC)
Medical Project Director Ronald L. Krome, MD
OMERAD Project Director Jack L. Maatsch, PhD Audit Committee
| Manager, ACEP Medical Education Department Charles B. Maclean, PhD
MEDICAL TASK FORCE Chairmen
OMERAD Test Development Team
I
C. C. Roussi, MD
Medicine (6 members)
George Podgorny, MD
Surgery/Trauma (7 members)
Ronald P. White, MD
Cardiorespiratory (5 members)
A. L. Jenkins, MD Karl G. Mangold, MD
EMS Administration Systems (4 members) Physician/Patient and Legal/Ethical (5 members)
Multiple Choice Battery Patient Management Problems Stimulus Films and Slides Simulated Patient Encounters Validation and Scoring Systems
ABEM: The American Board of Emergency Medicine will be incorporated during 1976. It will function as the independent certifying body for the specialty of emergency.medicine. Only ABEM can determine eligibility requirements and examination administration and scoring procedures. COBE: The Committee on Board Establishment is charged with securing the necessary recognition for the specialty of emergency medicine and overseeing the examination development process. COBE reports to the Board of Directors of ACEP and Will be dissolved when ABEM has its first meeting. CEC: The Contract Executive Committee is a seven-member body composed of ACEP and OMERAD administrative personnel. Jtdecides questions of contract specifications, products, personnel, task performance, disputes, appeals and termination.
PMD:The Planning; Monitoring and Documentation group is composed of ACEP members and OMERAD professional staff not directly involved in developing the examination. They formulate, resolve and/or document methodological and substantive Policy issues that arise during the development of the examination. AUDIT COMMITTEE: The Audit Committee is composed of the five chairmen of the Medical Task Force Committees and the medical project director.
~ig. 1. Organization chart of team developing the certification examination in emergency medicine. J~)
July 1976
V o l u m e 5 N u m b e r 7 Page 531
GUIDELINES FOR THE SELECTION OF CONTENT TO BE TESTED General Guidelines for all Item Types Remember this is a criterion-referenced test. You are n o t trying to select deliberately hard or tricky test items. Try to select: •
frequently encountered cases and problems
•
necessary knowledge (clinical or basic science) that must be r e m e m b e r e d at all times during practice
•
problems and knowledge related to time-sensitive decisions and treatments (where candidate would not have time to look up necessary information)
•
problems and knowledge related to life-threatening situations
•
problems or knowledge that is common to all ED settings (Not geographic or location-specific laws, diseases, treatments, drugs, etc.) Scenario Selection Guidelines (All Simulation Formats) Try to select cases that: •
require differential diagnosis
•
incorporate commonly associated problems
•
include legal-ethical, psychiatric and/or physician-patient relation problems
•
are frequently encountered and central to the content area assigned
•
can be rapidly and appropriately disposed of in the ED
•
have significantly different outcomes depending on diagnosis and treatment
• do not require the use of special equipment or expensive, bulky or nonexistent simulators Multiple Choice Selection Guidelines Try to select: •
frequently used general rules or principles
•
knowledge that is the end-product of other related knowledges. (If the candidate knows this, then he/she must also know those other things)
•
absolutely essential knowledge for proper ED practice. (Avoid isolated facts, abstract, remotely related basic science knowledge, rare diseases, etc.)
•
specific applications or decision points having unambiguous and generally agreed upon correct and incorrect alternatives
•
content that does not require an elaborate, lengthy description of preconditions or qualifications in ordering tests
Slide or Photograph Selection Guidelines Try to select: •
visual materials that test general interpretative skills
•
visual materials that commonly require immediate interpretation and use in the ED
•
visual materials that, when projected on a large screen, knowledgeable candidates can clearly see and easily interpret.
F i g . 2. Guidelines for the selection of test items being followed by members of the Medical Task Force. with each other to see who knows the most of this t y p e of information. In contrast, a criterion-referenced test a t t e m p t s to rat i o n a l l y s a m p l e essential k n o w l e d g e in p r e d e t e r m i n e d specific a r e a s of medical knowledge. The m i n i m u m acceptable performance is d e t e r m i n e d in advance by the c a n d i d a t e ' s peers. All c a n d i d a t e s t a k i n g the test can pass if t h e y m e e t p r e d e t e r m i n e d board s t a n d a r d s , or all can fail if t h e y don't. C a n d i d a t e s compete w i t h previously set s t a n d a r d s , not w i t h each other. The specific k n o w l e d g e and skill a r e a s t h a t will be t e s t e d by t h e E M S C E h a v e been i d e n t i f i e d and docuPage 532 Volume 5 Number 7
m e n t e d by the Medical Task Force and reviewed by the A u d i t C o m m i t t e e . This d o c u m e n t will be a v a i l a b l e to c a n d i d a t e s and A C E P m e m b e r s before t a k i n g the exar~' i n a t i o n . C u r r e n t l y , t h e T a s k Force is g e n e r a t i n g test items, from the p r e d e t e r m i n e d content areas, in several different formats following g u i d e l i n e s for the selection of test items (Figure 2). A criterion-referenced test will be totally composed of items t h a t m e a s u r e e s s e n t i a l a n d f r e q u e n t l y used knowl" edge in e m e r g e n c y medicine w i t h o u t r e g a r d to how easy or h a r d t h e question is. At first glance t h e t e s t may a p p e a r to be easy compared to a norm-referenced test. However, c a n d i d a t e s will be expected to respond correct' July 1976 ~ ] ~ P
ly to a very h i g h p e r c e n t a g e of these items since t h e y #e directly r e l a t e d to essential p a t i e n t care. As a consequence, o b t a i n i n g c e r t i f i c a t i o n m a y or m a y n o t be ~ s i e r w i t h a c r i t e r i o n - r e f e r e n c e d t e s t d e p e n d i n g on the s t a n d a r d s set in advance by ABEM. This leads us to a comparison of t h e scoring and certification decisions of the two t y p e s of tests.
TEST SCORING The p r i m a r y o v e r r i d i n g objective of a norm-referenced certification e x a m i n a t i o n is to spread out c a n d i d a t e scores. The g r e a t e r the spread, the better, especially at the lower end of the scale where the cut-off point for failure is established. The l a r g e r the gap between the scores of the bottom 15% to 20% a n d the rest of the scores, the less e m b a r r a s s i n g it is to r a t i o n a l i z e the selection of t h e cut-off point and the easier it is to e x p l a i n to failed candidates w h y t h e y a r e less competent t h a n other candidates who scored a few points h i g h e r and were certified. ,Remember, this cut-off point is a s t a t i s t i c a l l y d e t e r m i n e d score b~sed on group scores. This "pass" score can v a r y with each group of c a n d i d a t e s or each new version of the test. T h e r e is no r e f e r e n c e to e x t e r n a l l y e s t a b l i s h e d standards of performance n e c e s s a r y to c o m p e t e n t l y practice the specialty. In contrast, t h e criterion-referenced test is scored according to s t a n d a r d s (criteria) of acceptable performance in specific competency a r e a s developed when the t e s t is developed. E a c h c a n d i d a t e is j u d g e d independently, not according t ° how other c a n d i d a t e s t a k i n g the test at t h e same t i m e perform. CERTIFICATION DECISION MAKING The t e s t scores p r e s e n t e d to the Board are different for the two a p p r o a c h e s to t e s t i n g and so is the Board's role in Raking t h e decision to certify a c a n d i d a t e . For normreferenced tests, the Board d e t e r m i n e s or approves a failure p e r c e n t a g e b a s e d on group scores. Clerks or computers a p p l y the necessary statistics to produce t h a t perI'centage a n d notify c a n d i d a t e s of the outcome. On t h e o t h e r hand, the proposed criterion-referenced test will provide the A B E M w i t h a profile of scores on each candidate. The c o m p o n e n t scores or competencies t h a t will m a k e up t h e c a n d i d a t e ' s profile have not y e t been determined. However, t h e y will reflect the c a n d i d a t e ' s Iknowledge a n d s k i l l s in 22"specific m e d i c a l c o n t e n t bcategories. The p e r c e n t a g e of items t h a t will be allocated to each of the 22 different medical c o n t e n t categories COmposing the specialty, e m e r g e n c y medicine, has been approximately d e t e r m i n e d (Table). The categories were adapted from those produced by the Conference on Education of the P h y s i c i a n in E m e r g e n c y Medical Care. 1 !Percentage a l l o c a t i o n s a r e b a s e d on a q u e s t i o n n a i r e ~ubmitted to a s a m p l e of 135 A C E P m e m b e r s a s k i n g them to d e t e r m i n e t h e r e l a t i v e i m p o r t a n c e of e a c h Category for certification testing. Each c a n d i d a t e ' s profile of scores will be compared w i t h ~re-established s t a n d a r d s for each component score or COmpetency. E x t e n s i v e v a l i d a t i o n t e s t i n g of d i f f e r e n t groups of p h y s i c i a n s a n d medical s t u d e n t s will help t h e l~oard e s t a b l i s h these s t a n d a r d s before the first e x a m i n a tion. A decision to certify or not to certify will r e q u i r e
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July 1976
Table PERCENTAGE OF TEST ITEMS ALLOCATED TO MEDICAL CONTENT CATEGORIES
% 13 7 7
Category Cardiovascular disorders (traumatic and nontraumatic) Abdominal disorders
7 7 7 7
Ear, nose, throat, head and neck injuries (traumatic and nontraumatic) Pulmonary disorders Skeletal injuries Traumatic disorders Urogenital disorders
6
Infancy and childhood disorders
5
Metabolic, allergic and toxicologic disorders Fluid and electrolyte problems Neurological disorders
4 4 3
Behaviorial disorders
3 3
Burn and cold exposure Critical infections
3
3
Emergency medical services system (including disaster planning and management) Eye disorders (traumatic and nontraumatic) Legal-ethical
2 2
Blood disorders Physician-patient skills
2 1 1
Emergency department a~dministration Dental emergencies Integumental disorders
3
100% j u d g m e n t s of v a r y i n g complexity. Obviously, candidates c l e a r l y m e e t i n g all s t a n d a r d s in each competency will r o u t i n e l y be certified a n d those failing to m e e t s t a n d a r d s in most a r e a s will r o u t i n e l y not be certified. It is the g r a y a r e a where j u d g m e n t s become more complex. For example, a c a n d i d a t e m a y m a r g i n a l l y fail to m e e t one or more s t a n d a r d s b u t excell in other r e l a t e d areas. R e m e m b e r the t e s t scores are estimates of how much the c a n d i d a t e s rea l l y know. In a n o t h e r case, a c a n d i d a t e ' s performance m a y be m a r k e d l y different on one test format, eg, multiple choice questions, in comparison to the o t h e r formats. T h i s " h a n g up" m a y a r t i f i c i a l l y l o w e r a score below s t a n d a r d s in several competencies. F i n a l l y , a candidate m a y m a r g i n a l l y pass or fail in all competencies b u t with the m a r g i n a l failures in r e l a t i v e l y less i m p o r t a n t competencies. These and still other special cases r e q u i r e complicated professional j u d g m e n t s by ABEM. The overall j u d g m e n t
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process is more complex, less objective and, as a result, more e x p e n s i v e t h a n in n o r m - r e f e r e n c e d tests b u t the final decision to certify is both i n d i v i d u a l i z e d a n d rational. Since c a n d i d a t e s a r e competing with s t a n d a r d s , it is e n t i r e l y possible t h a t t h e Board will notify failing cand i d a t e s of t h e i r specific a r e a s of deficiency a n d t h e n l a t e r r e t e s t those c a n d i d a t e s in specific deficiencies. These decisions have not been m a d e by the ABEM as yet b u t t h e y are consistent w i t h the criterion-referenced test s t r a t e g y chosen by ACEP. SUMMARY
The concept b e h i n d t h e p r o j e c t e d E M S C E , t h e development schedule, its c u r r e n t s t a t u s and the organization of the t e a m developing the e x a m i n a t i o n have been presented. The norm-referenced test s t r a t e g y commonly used in medical certification e x a m i n a t i o n s was compared with the criterion-referenced test s t r a t e g y being used in the d e v e l o p m e n t of the EMSCE. The two t e s t s t r a t e g i e s
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influence the medical content selected for test items~ well as t h e method of e v a l u a t i n g professional compete~ cies for p u r p o s e s of c e r t i f i c a t i o n . W h i l e criteri~J referenced tests are more exp6nsive to develop, we feelil t h e long r u n t h e y w i l l be a d o p t e d by m o s t medici specialties as the most r a t i o n a l approach to certificati~ a n d recertification. The objective of this article is best s u m m a r i z e d byt spontaneous r e m a r k made by a m e m b e r of the Medie~J T a s k Force d u r i n g the r e c e n t I t e m D e v e l o p m e n t W0r~J shop. "My God,, he stated, This r e a l l y is a different ty~ of t e s t t h a n we ve ever taken! How will we ever explaiI to c a n d i d a t e s t h a t it s not j u s t . a lot of t r i c k questions?fl REFERENCES 1. Report on the Conference on Education of the Physicia~ i~l Emergency Medical Care, Council on Medical Education, AM~']
1973.
July 1976 J ~
sPECIAL CONTRIBUTION
The ED Record
Friend or Foe
James E. George, MD, JD Woodbury, New Jersey
JACEP 5:535540, July 1976. emergency department record, medicolegal implications. George JE: The ED record - - friend or foe.
INTRODUCTION
Today, for m a n y reasons, e m e r g e n c y d e p a r t m e n t (ED) and other hospital record requirements are much more stringent t h a n even a few y e a r s ago. S t a t e laws have been passed in some j u r i s d i c t i o n s m a n d a t i n g stricter ED record keeping. F e d e r a l l y r e l a t e d h e a l t h care p r o g r a m s , such as M e d i c a r e a n d M e d i c a i d , o p e r a t e u n d e r r e g u lations d e m a n d i n g more complete ED record documentation. A c c r e d i t i n g o r g a n i z a t i o n s , s u c h as t h e J o i n t Commission on A c c r e d i t a t i o n of Hospitals (JCAH), h a v e established some of the most comprehensive ED record procedures. The i n s u r a n c e i n d u s t r y w i t h its need to d e t e r m i n e coverag e has e x e r t e d g r e a t practical force in developing more d e t a i l e d medical records. The p a s s a g e of t h e PSRO law has t h r o w n into s h a r p focus t h e federal g o v e r n m e n t ' s desire to cod,ify h e a l t h care s t a n d a r d s . C e r t a i n forensic medical events such as rape, b a t t e r e d children and intoxicated drivers have emphasized meticulous ED r e c o r d k e e p i n g as t h e only m e a n s by which justice can be accomplished. F i n a l l y , the t r u e significance of an a d e q u a t e ED record has been d r i v e n home to t h e e m e r g e n c y p h y s i c i a n b y the plague of medical m a l p r a c t i c e litigation s u r r o u n d i n g t h e practice of m o d e r n medicine. The ED record is critical to a successful m a l p r a c t i c e defense. It is the first, best and sometimes only chance for the e m e r g e n c y physician to withstand a m a l p r a c t i c e lawsuit, Dr. George is a practicing emergency physician at the Underrood-Memorial Hospital in Woodbury, New Jersey. He is also a lawyer and editor of the Emergency Nurse Legal Bulletin and the Emergency Physician Legal -Bulletin. Further information about the Bulletins can be obtained from MED/LAW Publishers, Inc, PO Box 293, Westville, Nev~ Jersey 08093. This article was first published in the Emergency Physician " Legal Bulletin, Volume 1, Number 3, Summer 1975, copyright 1976 MED/LAW Publishers, Inc, reprinted with permission.
J~P
July 1976
The following discussion a t t e m p t s to f a m i l i a r i z e t h e e m e r g e n c y physician with the medicolegal ramifications of t h e ED record. Statutes and Regulations
Several s t a t e s including K a n s a s , Colorado, Massachusetts and New York have p a s s e d s t a t u t e s and r e g u l a tions r e q u i r i n g t h a t c e r t a i n d e t a i l s a p p e a r in the ED record i n c l u d i n g p a t i e n t identification, test r e s u l t s (eg, lab, x-ray, etc), diagnosis, t r e a t m e n t and disposition of the case and the s i g n a t u r e of t h e t r e a t i n g physician. Some states, such as Colorado, even r e q u i r e t h a t the t r e a t i n g p h y s i c i a n be responsible for t h e a d e q u a t e completion of t h e E D record. F i n a l l y , some provision is made for storage of such records in a record room facility. The U S D e p a r t m e n t of H e a l t h , E d u c a t i o n and Welfare has f o r m u l a t e d r e g u l a t i o n s or s t a n d a r d s as conditions of hospital E D ' p a r t i c i p a t i o n in Medicare and Medicaid. It is g e n e r a l l y r e q u i r e d t h a t a d e q u a t e records, c o n t a i n i n g the i n f o r m a t i o n a l r e a d y listed, be k e p t on e v e r y p a t i e n t t r e a t e d in the ED. It is also r e q u i r e d t h a t ED records be organized by a medical record l i b r a r i a n or equivalent, int e g r a t e d w i t h i n p a t i e n t and o u t p a t i e n t records when app r o p r i a t e and k e p t as long as r e q u i r e d by state s t a t u t e s of l i m i t a t i o n s , sometimes up to 10 years. Recordsmanship
Most e m e r g e n c y physicians view the ED record as an u n a v o i d a b l e burden, to be gotten rid of as quickly as possible. In fact, t h e ED record is a medicolegal challenge of Lhe h i g h e s t priority. The ED record should be constructed by the e m e r g e n c y physician so t h a t it presents a n accurate, logical a n d complete story as d e t e r m i n e d by the facts. The issues of abbreviations and legibility remain s o m e w h a t clouded. It is c e r t a i n l y a p p r o p r i a t e for t h e e m e r g e n c y physician to use accepted medical abbreviations in the ED record. It is not so c e r t a i n w h e t h e r these a b b r e v i a t i o n s are a p p r o p r i a t e w h e n w r i t i n g the diagnosis b e c a u s e n o n m e d i c a l p e r s o n n e l , such as r e c o r d r o o m clerks, b i l l i n g clerks, p r i v a t e a n d g o v e r n m e n t a l insurance clerks, m u s t r e a d and deal with the diagnosis as p a r t of t h e i r job. This issue has been resolved in i n p a t i e n t
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