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Emergency Medicine Australasia (2015) 27, 148–151

doi: 10.1111/1742-6723.12374

TRAINEE FOCUS

The role of short courses in Australasian emergency medicine training Rob MITCHELL,1 Joe-Anthony ROTELLA,2 Jennifer JAMIESON3 and Andrew PERRY4 1 Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia, 2Department of Emergency Medicine, Austin Health, Melbourne, Victoria, Australia, 3Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia, and 4Department of Emergency Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia

Given that a number of specialty colleges require their trainees to complete short courses, should ACEM follow suit? The accompanying articles by Williams1 and MacKenzie2 explore both sides of this debate, and this perspective piece provides broader context to the discussion.

Background For the purposes of this article, short courses are defined as courseworkbased training opportunities, of less than 2 week’s duration, delivered independently of hospital-based clinical teaching programmes. A growing number are available to emergency medicine (EM) clinicians and cover a variety of areas including trauma, resuscitation, ultrasound, paediatric emergencies and research methods. A sample of popular courses is provided in Box 1. The next edition of the Trainee Focus section will consider the role and value of longer, universitybased degree programmes focussed on EM. As scientific knowledge and trainee numbers in EM expand, demand for short courses is likely to grow. Other potential drivers of attendance include future increases in professional development (PD) allowances, and more rigourous safety and quality standards in relation to life support skills

and training.3,4 The trend towards subspecialisation in EM might also precipitate new and expanded courses in areas such as toxicology, pre-hospital and retrieval medicine and international EM.

Benefits Williams1 and MacKenzie2 have listed many of the benefits of undertaking short courses, including opportunities to develop new skills in relevant areas; discuss recent knowledge advances with content experts; practice new or revised skills in a safe environment (e.g. through scenarios and simulation); access purpose-built printed and electronic resources; and network with colleagues. Courses also provide a quarantined period of time free of the distractions and interruptions of clinical service delivery, allowing participants to have an immersive learning experience. Consistent with these benefits, there is evidence that participation in short courses can improve knowledge and retention of emergency algorithms.5–7 Short courses can also be beneficial in standardising the management of critical conditions. For instance, Advanced Life Support (ALS) provides training in the Australian Resuscitation Council’s arrest algorithms,8

Correspondence: Dr Rob Mitchell, Department of Emergency Medicine, Royal Brisbane and Women’s Hospital, Butterfield Street, Herston, QLD 4006, Australia. Email: [email protected] Rob Mitchell, MBBS (Hons), BMedSc (Hons), MPH&TM, Emergency Registrar; JoeAnthony Rotella, MBBS, BSc, Emergency Registrar; Jennifer Jamieson, MBBS, BBiomedSc, Emergency Registrar; Andrew Perry, MBBS, FACEM, Staff Specialist. Accepted 22 January 2015

whereas Early Management of Severe Trauma (EMST) and Emergency Trauma Management (ETM) promote systematic approaches to trauma assessment.9,10 In the interests of a consistent approach to paediatric emergencies, the Royal Australasian College of Physicians recommends Advanced Paediatric Life Support (APLS) as the standard of life support training for staff providing care to children and adolescents.11

Drawbacks Although clinically oriented short courses are generally highly regarded by trainees, there are issues associated with compulsory participation. First, they can be expensive. An example from the upper end of the scale is the 3 day EMST course, for which the cost in 2015 is $3015, excluding travel and accommodation.12 There is an additional imposition on rural and regional trainees, who are often compelled to travel to larger centres in order to participate. Second, waiting times can be long when trainee demand exceeds the supply of places. This has been an ongoing challenge for EMST. A third issue is that mandatory courses potentially consume valuable PD leave that could be used for other purposes (e.g. exam preparation, conference participation and attendance at other relevant courses). The more fundamental issue, as discussed by Williams1 and MacKenzie,2 is the lack of evidence linking completion of short courses with improved patient outcomes. This reflects the challenges of evaluating educational interventions in a clinical context, given that training is just one component of a system of care. Although a 2014

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BOX 1. Sample of short courses of relevance to EM clinicians Course Advanced Life Support (ALS) course Advanced Paediatric Life Support (APLS) course Advanced and Complex Medical Emergencies (ACME) course Advanced Paediatric Emergency Medicine (APEM) course Early Management of Severe Trauma (EMST) course Emergency Trauma Management (ETM) course Advanced Life Support in Obstetrics (ALSO) course Introductory Ultrasound for Emergency Medicine course Emergency Medicine Expert Point of Care Ultrasound (POCUS) course Emergency Medicine Research Short Course Major Incident Medical Management & Support course

Cochrane review of the Advanced Trauma Life Support (ATLS) programme, from which EMST is derived, found no high-quality evidence of improved injury outcomes, it also failed to identify any data to suggest that it is not valuable.13 As Buck acknowledges in the accompanying article, participation in regular, structured, workplace-based, multidisciplinary simulation exercises – as part of a broader, longitudinal training programme that incorporates appropriate teaching, supervision and feedback – is likely to be a more effective means of developing clinical skills, decision-making abilities and capacity for teamwork.14

Approaches by other colleges Several specialty colleges require that their trainees undertake short courses. For example, the Royal Australasian College of Surgeons mandates several workshops pertaining to surgical practice; these include Care of the Critically Ill Surgical Patient, the Australian and New Zealand Surgical Skills Education and Training (ASSET) course and EMST.15 Similarly, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) requires that trainees undertake surgical skills and communication courses.16 In the field of critical care, the Australian and New Zealand College of

Responsible organisation Australian Resuscitation Council APLS Australia ACEM APEM Australia Royal Australasian College of Surgeons Emergency Trauma Management ALSO Asia Pacific Ultrasound Training Solutions Australian Institute of Ultrasound Monash University School of Public Health and Preventative Medicine MIMMS Australia

Anaesthetists (ANZCA) mandates completion of ALS (or equivalent) as well as the Effective Management of Anaesthetic Crises (EMAC) course.17 The College of Intensive Care Medicine requires trainees to undertake six courses during their training, covering topics such as advanced airways skills and ultrasound.18 In many cases, these courses have been developed or adapted by the relevant college and are exclusively provided by that organisation (e.g. ASSET and the RANZCOG Basic Surgical Skills Workshop). In other instances, courses are compulsory but not delivered by the college itself (e.g. ANZCA’s ALS requirement). In the case of the EMAC course, ANZCA accredits independent skills centres to facilitate the course according to College specifications.

ACEM position and experience Unlike the College of Emergency Medicine in the UK, 19 ACEM does not mandate courses as part of its specialty training programme. However, it acknowledges that ‘there are many excellent and worthwhile courses available to individuals who wish to gain specific skills that they identify would be of benefit to them’ (Dianne King, Chair, ACEM Council of Education, personal correspondence). This approach is consistent with ACEM’s role

in setting standards, defining curricula and facilitating assessment, but not directly delivering EM education and training. The ACEM Trainee Committee is supportive of this approach and passed a resolution to this effect in 2013. Although ACEM does not require specialty trainees to undertake courses, it has a different approach for the Certificate and Diploma programmes. In the case of the former, both Basic Life Support and ALS are required. 20 Diploma candidates must undertake Emergency Life Support (ELS) and one of EMST, Advanced and Complex Medical Emergencies (ACME), EMAC, APLS, Advanced Paediatric Emergency Medicine (APEM) or ETM.21 The extent to which ACEM trainees participate in short courses of their own volition is unknown, although some relevant data come from the trainee research requirement (TRR). Greater than 90% of trainees meet or intend to meet the TRR by way of coursework,22 reflecting that this option is considered to be a more efficient and effective means of achieving the curriculum’s research objectives.22,23 A previous article in this journal has encouraged ACEM to enhance trainee access to TRR-accredited courses, for instance by negotiating reduced registration fees and encouraging training providers (e.g. universities) to develop courses specifically focused on EM research.22

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Enhancing access Even in the absence of a compulsory course requirement, accessing courses can be difficult for trainees. Relevant factors include availability of positions, cost (including travel and accommodation) and leave allowances. Anecdotally, the latter two are the most important determinants and are influenced by employment rather than training arrangements. Given that health services and their patients arguably benefit from trainees completing short courses, there is a strong case for employer subsidies of selected programmes. All Australian states and territories include some form of PD funding in their medical officer industrial agreements to assist with training costs and/or attendance at relevant courses. At the generous end of the scale, South Australian trainees are provided with up to A$8,000 per year, with consultants entitled to $21 500.24 This is coupled with 2 weeks of PD leave. Where PD funds are unavailable or exhausted, the Australian taxation system permits tax deduction of medical courses under certain circumstances.25 In New Zealand, trainees are employed by District Health Boards under a Multi-Employer Collective Agreement (MECA), which funds attendance at certain approved courses (with some restrictions on travel and accommodation costs). The MECA also allows for 12 weeks of education leave throughout training (on top of annual leave), as well as additional allowances for conference attendance.26

Conclusion Short courses can facilitate effective and efficient learning in important skill areas. Evidence for improved clinical outcomes is weak, but this reflects that multiple individual and systems factors impact on patient care. Consistent with its focus on standard setting and not educational delivery, ACEM does not currently require that its specialty trainees complete specific courses. This policy encourages trainees to take control of their own learning needs.

Given the approach of other Australasian colleges, and the potential educational and clinical benefits of short courses, there is value in revisiting the role of compulsory courses in EM education and training. Although there is widespread support for the College’s current policy, the accompanying articles indicate that alternate approaches can also be justified. Irrespective of College requirements, there is a strong argument for employers to enhance access to relevant educational opportunities. The quantity and quality of short courses focused on EM will continue to increase, providing more options for health services to support the professional development of emergency clinicians.

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Competing interests All authors are section editors for Emergency Medicine Australasia. AP is an instructor on the ETM course.

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1. Williams J. Should external short courses be a compulsory part of ACEM specialty training? Yes. Emerg. Med. Australas. 2015; 27: 155–7. 2. MacKenzie S. Should external short courses be a compulsory part of ACEM specialty training? No. Emerg. Med. Australas. 2015; 27: 158– 9. 3. Australian Commission on Safety and Quality in Healthcare. National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration. Sydney: ACSQHC, 2010. 4. Australian Commission on Safety and Quality in Healthcare. National Safety and Quality Health Service Standards. Sydney: ACSQHC, 2011. 5. Williams M, Lockey J, Culshaw S. Improved trauma management with advanced trauma life support (ATLS) training. J. Accid. Emerg. Med. 1997; 14: 81–3. 6. Ali J, Gana T, Howard M. Trauma mannequin assessment of management skills of surgical residents after advanced trauma life support train-

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training period. [Cited 12 Jan 2015]. Available from URL: http:// www.anzca.edu.au/training/2013 -training-program/pdfs/curriculum -appendix-one 18. College of Intensive Care Medicine. Training program. [Cited 12 January 2015]. Available from URL: http:// www.cicm . org.au / trainprogram 2014.php 19. College of Emergency Medicine. Curriculum from August 2010. [Cited 12 Jan 2015]. Available from URL: http://www.collemergencymed.ac .uk/Training-Exams/Curriculum/ Curriculum%20from%20August %202010 20. Australasian College for Emergency Medicine. Emergency medicine certificate. [Cited 12 Jan 2015]. Available from URL: https://acem.org .au/Education-Training/Certificate

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Enterprise Agreement 2013. Adelaide: Department of Premier and Cabinet, 2013. 25. Australian Taxation Office. Claiming self-education expenses – selfdevelopment courses. [Cited 18 Jan 2015]. Available from URL: https:// www . ato . gov . au / Individuals / Studying - and - student - debt / In -detail / Deductions - and - offsets / Claiming-self-education-expenses -self-development-courses/ 26. New Zealand Resident Doctors’ Association. District health boards NZ resident doctors’ association collective agreement. [Cited 18 Jan 2015]. Available from URL: http://www .nzrda.org.nz/wp-content/uploads/ 2011 / 05 / 2012-RDA-MECA-for -printing.pdf

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