CONCEPTS, COMPONENTS & CONFIGURATIONS education

Undergraduate Education in Emergency Medicine [Binder L, Emerrnan C, Tachakra S, Dick W, Epstein J: Undergraduate education in emergency medicine. Ann Emerg Mad October 1990;19:1152-

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h panel session on undergraduate education in emergency medicine from a worldwide perspective was conducted at the Sixth World Congress of Emergency and Disaster Medicine in Hong Kong in September 1989. Louis Binder, MD, of the Texas Tech University Health Sciences Center (USA) was the panel moderator. Other panel speakers were Charles Emerman, MD, Case Western Reserve University (USA); Sapal Tachakra, MD, Central Middlesex Hospital, University of London (United Kingdom); Wolfgang Dick, MD, University of Mainz (West Germany); and Joseph Epstein, ME), President of the Australasian College for Emergency Medicine (Australia). Louis Binder, MD: We will discuss many different aspects of undergraduate education in emergency medicine; the unique aspects of emergency medicine in the undergraduate curriculum; the potential contributions of emergency medicine to the general professional education of physicians; the aspects of emergency medicine that should be taught in the medical school curriculum; the interfaces with governmental, professional, and academic societies, and curriculum committees necessary to advance emergency medicine in the undergraduate curriculum; and the advising/career counseling/recruitment of emergency physicians at the medical student level. A discussion of emergency medicine content in the undergraduate curriculum must first assume a curriculum with a good basic sciences foundation in the basic pathophysiologic processes of high-impact emergency medicine diseases (eg, shock, infection, AIDS, fluid and electrolyte management and acid-based problems). Second, any proposed undergraduate emergency medicine curriculum must strive to use contact hours effectively. Plans calling for 150 or 200 contact hours per year are infeasible. To gain undergraduate curriculum access in competition with other disciplines requires a concise number of contact hours (20 to 40 per year), a defined set of educational objectives, and proof that these objectives can be accomplished. If used effectively, a small number of contact hours can achieve important educational objectives within the domain of emergency medicine. Year 1 of most medical school curricula concentrates on sciences basic to the practice of medicine. Students complete a large volume of didactic graduate level course work in these disciplines. They must correlate these basic sciences and their relevance to clinical practice and must gain clinical acumen that could be used in an emergency. Most medical schools provide early exposure to basic cardiac life support (CPR and management of the obstructed airway). Students can also benefit from learning basic skills in splinting and bandaging, immobilization techniques, and the field management of such conditions as flail chest or sucking chest wounds. These skills can be taught in 25 contact hours during year 1. To correlate the basic sciences with clinic practice, curricula with variable contact hours allowing clinical correlation time in the emergency department are desirable. For example, an acute ED presentation of diabetic ketoacidosis

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Annals of Emergency Medicine

Louis Binder, MD* El Paso, Texas Charles Emerman, MDt Cleveland, Ohio Sapal Tachakra, MD¢ London, England Wolfgang Dick, MD§ Mainz, West Germany Joseph Epstein, MDIt Victoria, Australia From the Texas Tech University Health Science Center, El Paso, Texas;* Case Western Reserve University, Cleveland, Ohio;'r Central Middlesex Hospital, University of London Medical School, London, England;* University of Mainz, West Germany;§ and the Australasian College for Emergency Medicine, Victoria, Australia) I Received for publication February 15, 1990. Accepted for publication April 4, 1990. Presented at the 6th World Congress of Emergency & Disaster Medicine in Hong Kong, September 1989. Address for reprints: Louis Binder, MD, Department of Emergency Medicine, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, Texas 79905.

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provides an opportunity to discuss fluid and electrolyte metabolism, insulin physiology and its effect on potassium, acid-base balance, and intermediary metabolism of alpha keto acids and glucose at the bedside. Year 2 of the curriculum is the bridge year, when clinical pathophysiology of discase, basic clinical assessment, and data acquisition skills are taught. Emergency medicine educators may contribute to this curriculum by instruction in clinical pathophysiology and emphasis on clinical correlations. A 20- to 30-hour "emergency presentations" curriculum divided between the ED and smallgroup tutorials (emphasizing problem-based learning) can accomplish a number of positive ends: the clinical presentation and pathophysiology of disease; symptom pursuit approach to the unscreened patient; components of a cogent and functional data base; and the appropriate mix of patient assessment, problem solving, and stabilization. C l a s s r o o m s i m u l a t i o n can be nicely s u p p l e m e n t e d by "real-life practicals" in the ED or busy ambulatory care milieu, and emergency physicians or ambulatory care physicians should provide instruction. In addition, many of the basic science courses stress the concept of clinical correlation, which could be done easily by emergency physicians. An interested or energetic department of emergency medicine could easily enter into the curriculum at this level. In year 3 students move to basic clinical training in the basic specialties (eg, internal medicine, surgery, pediatrics). Some schools do have curricula in emergency medicine, but the majority incorporate this into the fourth year to allow the emergency medicine clerkship to build on these basic experiences. If clinical emergency medicine is not incorporated here, the most appropriate role for emergency medicine is in any interdisciplinary didactic series in which multidisciplinary material is taught (eg, geriatrics, oncology, nutrition). The material selected for presentation should strive to complement rather than duplicate information taught elsewhere; by choosing interdisciplinary topics, emergency medicine provides a nice supplement to what is taught elsewhere in the curriculum at this stage. In addition, in year 3, the process 130/1153

of career specialty selection starts for most medical students, and in many institutions the undergraduate advisory process is dependent on the efforts of interested faculty. Academic emergency physicians interested in recruitment, access to students, and access to curriculum will find this both a receptive and p r o d u c t i v e niche in the undergraduate curriculum; often this is a pathway of little resistance. Year 4 allows for specialized experience and for individual variation based on career preference. This is the m o s t productive place for an emergency medicine clerkship as either a required clerkship (preferably) or an elective experience. Some medical schools require advanced cardiac life support and advanced tramna life support, which is often taught by emergency physicians and is appropriately placed in the year 4 curriculum. Documentation of the positive effect of an emergency medicine curriculum on students' data base is imperative if access to curriculum time is to be achieved. A common frustration (and one I've personally expcrienccd) is the contention by medical school curriculum committees, faculty from other specialties, and deans of education that emergency medicine material is taught substantially in the traditional clerkships. This contention ignores a number of important educational factors: the exposure and education of students to the didactics of resuscitation, to prehospital care, to the evaluation of undifferentiated patients, to important disease processes that present primarily and in their fullest spectrum in the ED, and to the need for education in those presentations that cross traditional specialty lines. The documentation of educational benefit in these areas o v e r a n d a b o v e the educational benefit of the traditional clerkships is not easily accomplished but is important in demonstrating a curriculum need for emergency medicine contact hours. We have recently completed this documentation for our own undergraduate t e a c h i n g c u r r i c u l u m with a controlled study, and our methodology has published elsewhere.1 Howevcr, this documentation will be necessary at many institutions for emergency medicine to advance successfully in the u n d e r g r a d u a t e c u r r i c u l u m of Annals of Emergency Medicine

most medical schools. Another important responsibility of academic emergency physicians is the identification and recruitment of future emergency physicians at the medical student level. The ED is a very h i g h - v o l u m e clinical milieu with a patient p o p u l a t i o n distinguished by acuity. Practitioners must enjoy the provision of acute care and resuscitation and must be able to care for many acutely ill and injured patients simultaneously. The diversity of the patient population is another distinguishing factor of the ED, and practitioners of emergency medicine must be comfortable with that diversity. Finally, the ED is one of the most distracting of practice environments. Large numbers of patients in different stages of evaluation; constant interruptions from patients, emergency medical services, trainees, nurses, and phone calls; needs for direct supervision of trainees in the department; and different contacts throughout the day from administrators, paraprofessionals, and consultants create frequent disruptions affecting patient care. Some persons function better in this sort of milieu than others, and my particular observation is that the "honors student," although excellent didactically, often functions poorly in the ED. Although some function well, m a n y are more comfortable without diversity and distractions and prefer to use their intellect in a narrower focus. It is not always the brightest students who do best in emergency medicine; it is the most adaptive ones - students who are comfortable with high acuity, managing distractions, managing large patient v o l u m e , and who have the skills to manage several patients simultaneously. With an acceptable level of academic a c h i e v e m e n t in medical school, the adaptive and resourceful student can become a very good emergency physician. These students attract my interest and are the ones that I recruit to this specialty. In addition, the attraction to the acutely ill patients, resuscitation, and case load diversity are positive traits. To recruit successfully, emergency physicians should increase contact with students at any available level. Undergraduate advising is one of the easiest places to start because there 19:10 October 1990

is often little competition; by working well with students, one gains quickly their confidence and a good reputation. Availability as a resource for students with questions about emergency medicine is important for successful recruitment. Recruitment efforts are also enhanced by a reputation of excellence in both patient care and u n d e r g r a d u a t e t e a c h i n g {both didactic and bedside), and by allowing students a liberal amount of procedural experience under appropriate supervision. This attracts both a larger quantity of students and the quality students to specialty exposure, and emergency medicine can subsequently recruit its share. There are several inherent advantages to the specialty of emergency medicine: it is enjoyable, is acute care oriented, allows immediate feedback and gratification on management decisions, and is a growing specialty that affords both protected and productive work time. Students will realize the potential within emergency medicine, and an increase in the number of future emergency physicians will naturally follow. C h a r l e s E m e r m a n , MD: W i t h a

sympathetic medical school administration and a very energetic group of emergency physicians, much can be accomplished. However, I am concerned that emergency medicine is not alone in attempting to increase contact time in the undergraduate c u r r i c u l u m . Virtually all medical specialties have asserted the need for more curriculum time to teach their respective specialty content and expressed a desire to increase their exposure to undergraduates. Unfort u n a t e l y , the t r e n d in m e d i c a l schools is reduction of required contact time in the clinical curriculum and a more flexible and "problemoriented" curriculum that allows the development of self-study habits and critical reasoning. Another concern is the nature of the senior year of medical school often no mandatory requirements, often extramural in nature, and often "audition-oriented," with seniors undertaking many extramural months of clinical training in their intended areas of s p e c i a l i z a t i o n . M e d i c a l schools prefer to graduate broadly trained physicians and are making curriculum changes to limit these excesses. In the United States, emergency 19:10 October 1990

medicine has achieved modest success at integration into the undergraduate curriculum. In an article by Sanders, a approximately 20% of medical schools had some emergency medicine course work in the first year, and another 15% to 20% had some emergency medicine course work in the second year. Much of this preclinical contact time is CPR and emergency medical technician training, which I believe should not be the focus of emergency medicine's undergraduate educational efforts. Rather, we should focus our preclinical teaching on the pathophysiology of emergency medicine diseases {eg, cardiac arrest, cerebral and cardiac ischemia, asthma, shock) to emphasize both our contribution to the knowledge base of these diseases and the academic nature of this specialty. In addition, 75% to 90% of medical schools incorporate most emergency medicine core content areas into the undergraduate medical curr i c u l u m ; u n f o r t u n a t e l y , at m a n y schools, this core content is often taught by other specialties. The opportunities for teaching emergency medicine pathophysiology exist in the curriculum, and academic emergency physicians must gain access to these opportunities. Other trends developing in academic medical centers will affect undergraduate medical education. These trends may be helpful in integrating emergency medicine into the u n d e r g r a d u a t e c u r r i c u l u m if exploited properly. The most prominent of these is economic: teaching hospitals are under great pressure to care for patients efficiently, yet make money. In the United States, teaching hospitals rely on reimbursement for inpatient care through Medicare Part A "diagnosis-related group" reimbursement, under which hospitals are paid a fixed sum of money to care for a patient with a given diagnosis. The economic impact on teaching hospitals has been enormous and affects the opportunities for students who learn from these patients. At our hospital, the length of stay for Medicare patients has fallen by about 30%, one third of our surgeries are done on a same-day or o u t p a t i e n t basis, and most preoperative evaluation is now conducted prior to admission. A premium has been placed on efficiently processing patients through Annals of Emergency Medicine

the hospital system. Residents and medical s t u d e n t s supervise a patient's care briefly while in the hospital for an invasive test but do not take part in symptom evaluation or in the formulation of a diagnostic or therapeutic plan. Often the patient is discharged from the hospital before test results are known, and continuity of care is lost for the students. An additional economic trend is a decrease in funding for graduate medical education despite the placement of r e s t r i c t i o n s on resident w o r k hours; this results in fewer residents with fewer committed hours to complete assigned patient care responsibilities. Increased stress on residents and faculty to care for patients has resulted in less time available to teach medical students. One of the responses of teaching hospitals is to use " p h y s i c i a n extenders" (house physicians, nurse practitioners, physician assistants), which limits clinical material available for undergraduate education. These trends have led to proposals for alterations in the undergraduate clinical curriculum, including an increased e m p h a s i s on a m b u l a t o r y (rather than inpatient) education for medical students. Because of tradition and economic limitations, the move toward ambulatory education has met with only limited success. In a busy clinic, there is little time for medical students to pursue or leisurely present undifferentiated symptomatology, and often there are no faculty who are adept or interested in either undifferentiated ambulatory care or ambulatory education. Subspecialists are uncomfortable with supervising a general internal medical clinic, and these faculty members have little incentive to participate in ambulatory care teaching; their tenure is derived from research outside the clinics, and the financial reward of undergraduate ambulatory education is limited. Some of these same factors, of course, affect emergency medicine. Tenure is not derived from supervising residents and students, and effective case discussion and teaching of clinical problem solving is unlikely to occur in a busy ED by an attending who is supervising residents, overseeing and/or managing resuscitations, managing cases directly, answering phone calls, interfacing with administration and ancillary person1154/131

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nel, and tending to p a t i e n t flow concerns. To become effective in teaching m e d i c a l students in the ED, academicians m u s t arrange for a portion of their facutty's t i m e to be devoted e x c l u s i v e l y to b e d s i d e t e a c h i n g . If faculty t i m e is dedicated to critiquing s t u d e n t s ' presentations and going over their cases, the d e v e l o p m e n t of their clinical reasoning and diagnostic and therapeutic skills will follow. In addition, dedicated didactic undergraduate teaching can take place during s t u d e n t - o r i e n t e d m o r b i d i t y and m o r t a l i t y c o n f e r e n c e s , s t u d e n t lectures, s t u d e n t case conferences, and p r o b l e m - o r i e n t e d learning sessions. The best strategy to c o m p e t e for scarce clinical c u r r i c u l u m t i m e is to d e m o n s t r a t e t h a t e m e r g e n c y physic i a n s can t e a c h m e d i c a l s t u d e n t s " a m b u l a t o r y m e d i c i n e " in its broadest s e n s e r a t h e r t h a n " e m e r g e n c y m e d i c i n e , " and to d e m o n s t r a t e successful t e a c h i n g of c l i n i c a l p r o b l e m solving, diagnostic, and t h e r a p e u t i c skills in this undifferentiated milieu. T h i s w i l l r e q u i r e c o m m i t m e n t by c h a i r m e n , d i r e c t o r s , and l e a d e r s of emergency medicine, will be t i m e intensive for our academic faculty, and will require adequate faculty preparation and a c a d e m i c and financial reward; however, it will result in the successful entry of emergency medicine into the medical school curricul u m worldwide. Sapal T a e h a k r a , M D : A d v a n c i n g undergraduate emergency medicine e d u c a t i o n is a t i m e l y subject. This new specialty of ours needs a significant boost to its image, and opport u n i t y exists to progress faster i n t o the u n d e r g r a d u a t e c u r r i c u l u m than other specialties could at our stage. What strategies can we use to acc o m p l i s h this? T h e first is to build on o u r s t r e n g t h s , t h e g r e a t e s t of w h i c h is the variety of clinical material t h a t goes t h r o u g h o u r d e p a r t m e n t s . M a j o r or m o d e r a t e s t r e t c h e r cases (eg, i n j u r y cases, chest infection, a b d o m i n a l pain, g y n e c o l o g i c a l disorders) can be used for teaching, a n d t h e w a l k i n g w o u n d e d can be e q u a l l y effectual. Both types of patients present opportunities for ongoing s i t u a t i o n a l teaching. D u r i n g resuscitation, students may perform chest compressions, practice intubation on the cadaver if the patient expires, or m a y be taught b e r e a v e m e n t counseling w i t h families. A n o t h e r strength is our variety and 132/1155

n u m b e r of staff available for teaching. C o n s u l t a n t s and senior registrars (senior residents) m a y discuss w i t h students a particularly difficult case encountered earlier, an abnormal pathology result on a particular patient, or the finer points of chest auscultation in the m a n a g e m e n t of a m a j o r injury. O u r n u r s i n g and t e c h n i c i a n staff is capable of teaching students h o w to a p p l y p l a s t e r or r e p a i r a wound, and the ambulance crew teaches basic life support e x t r e m e l y well, perhaps better than we do. A s e c o n d strategy is to l i m i t our weaknesses. Our distraction-filled clinical e n v i r o n m e n t is a potential liability, requiring adaptability and p r o p e r t i m e m a n a g e m e n t s k i l l s to t e a c h e f f e c t i v e l y . For e x a m p l e , in small group teaching, mapping out a t o p i c (ie, l e t t i n g s t u d e n t s m e n t i o n various factors r e l a t i n g to overdose) p e r m i t s the i n s t r u c t o r to leave the r o o m to a n s w e r a p h o n e call w h i l e the students continue with the map. When the instructor returns they can review w h a t they have m a p p e d and continue w i t h the session. A n o t h e r strategy is to use a variety of t e a c h i n g aids and m o d e m s . Slide presentations can be used for a very rapid tutorial, a skeleton can be used to teach the a n a t o m i c basis of musculoskeletal injuries, or students can be assigned to review a topic on your behalf (either at the bedside or for formal presentation). These strategies arc t i m e efficient for faculty, and the s t u d e n t s serve as e d u c a t o r for b o t h the i n s t r u c t o r and t h e m s e l v e s (emp h a s i z i n g t h e i m p o r t a n c e of selfdirected learning). A n o t h e r teaching m e t h o d that preserves t i m e flexibility is the topic review, w h i c h is used c o m m o n l y in orthopedics. Students will prepare a p r e s e n t a t i o n on fractures of the femur: one presents the pathophysiology, one the diagnosis and management, and another the complications. This w o r k s well if students are properly supervised and directed. A n o t h e r m e t h o d is the case review, in w h i c h records of interesting cases can be reviewed. Yet another is the group project; each of our s t u d e n t groups is expected to do a project during the four weeks w i t h us and thereby learn how to w o r k as a group. We also review the use of r e s u s c i t a t i o n tools (ie, the defibrillator and other advanced life s u p p o r t equipment), major a c c i d e n t p o l i c i e s , r a d i o l o g i c a s s e s s m e n t of Annals of Emergency Medicine

c o m m o n films, and the integration of clinical information in the ED. A t h i r d s t r a t e g y is to a n s w e r the v a r i o u s i m p o n d e r a b l e s . S h o u l d we have a core curriculum? I am not entirely sure that we should. The broad-based n a t u r e of this s p e c i a l t y and the different levels of knowledge that s t u d e n t s possess have m a d e it d i f f i c u l t to i m p l e m e n t one in the U n i t e d Kingdom. W h i c h year in the c u r r i c u l u m and h o w m a n y at a time? T h e e x p e r i e n c e of d e a n s and subdeans worldwide with emergency m e d i c i n e as a fixed c l e r k s h i p indicates t h a t the o p t i m u m n u m b e r is four: a four-week rotation in the latter part of the next-to-last year or the early part of the last year. Are "joint term" rotation with other specialties desirable? Joint terms will likely be a fact of life in t h e U n i t e d K i n g d o m , and we m a y have to accept t h e m gracefully. However, strategies m u s t be p l a n n e d to i n t e g r a t e the r o t a t i o n s so as to use the best teaching of both specialties and to ensure that students are not a w a y f o r s i g n i f i c a n t p e r i o d s on r o u n d s or in t h e o p e r a t i n g r o o m . S h o u l d w e be a c c e p t i n g " s h a d o w h o u s e m e n " (senior s t u d e n t rotators) i n t e r e s t e d in l e a r n i n g r a p i d assessm e n t skills? Are deans prepared to send you shadow h o u s e m e n , and do you have the t i m e to take t h e m on? A final and m o s t i m p o r t a n t strategy is to use " s t u d e n t power." Student p o w e r (using the e n t h u s i a s m of u n d e r g r a d u a t e s to l o b b y school adm i n i s t r a t i o n for e m e r g e n c y m e d i c i n e c u r r i c u l m n time) is i n c r e a s i n g rapidly in t h e s e t t i n g of a c o n c i l i a t o r y and m o r e supportive medical school establishment. When looking through clerkship a s s e s s m e n t forms, e m e r g e n c y m e d i c i n e seems to come out on top consistently, both in the U n i t e d K i n g d o m and elsewhere. In r e s p o n s e to " s t u d e n t p o w e r , " t h e r e are visionary deans w h o believe that e m e r g e n c y m e d i c i n e has m u c h to c o n t r i b u t e to u n d e r g r a d u a t e education. Other trends and concepts that w i l l affect u n d e r g r a d u a t e e d u c a t i o n in e m e r g e n c y m e d i c i n e deserve m e n tion. A t the Edinburgh conference, medical educators in the United K i n g d o m for t h e first t i m e agreed that the purpose of the undergraduate c u r r i c u l u m is to t r a i n p r i m a r y care physicians and "general practit i o n e r s . " T h i s is a t r e n d in o t h e r 19:10 October 1990

countries as well, and it provides emergency medicine with a great opportunity. On both sides of the Atlantic, family physicians have promised a great deal in this area but have delivered little. A declining applicant pool for medical school positions in m a n y countries means that there will be fewer students available for recruitment into emergency medicine. In view of the declining applic a n t and s t u d e n t pool, we m u s t m a i n t a i n teacher e n t h u s i a s m and self-belief. In developing countries, the specialty of emergency medicine is not well established, and teaching programs in emergency medicine are important in aiding specialty deveL opment there. Despite our high service load and c o m m i t m e n t , we will not advance undergraduate education in emergency medicine w i t h o u t increased commitment to undergraduate teaching. This requires the dedication of time, resources, and effort. It also requires the education of our faculty and registrars in instructional skills: how to teach at the bedside, how to teach procedures, how to lecture, and how to conduct small group teaching. We need to "hijack" undergraduate teaching, do it better than other specialties, and do it without compromise of our postgraduate training programs. For these reasons, our department favors faculty and registrar applications from people with initiative and c o m m i t m e n t to undergraduate education. Students quickly recognize which departments are committed to teaching and which faculty excel as educators, and this can boost our student power and our case for additional curriculum time. This is accomplished by volunteering for and participation in introductory courses, m o c k boards, and revision courses (though unpopular and time consuming) and by participation on curriculum committees, academic committees, and board of studies. "Packing" these committees with our own faculty and with articulate people who advocate emergency medicine similarly advances our cause. Finally, to exchange successful teaching ideas and curricula for undergraduates, we need international organizations and meetings to aid one another. The medical students of today are the professors of medicine and surgery of tomorrow; by raising 19:10 October 1990

t h e m p r o f e s s i o n a l l y on excellent e m e r g e n c y medicine teaching, we can i n s t i t u t i o n a l i z e the place for emergency medicine in the undergraduate curriculum and achieve a quantum leap for the specialty. Wolfgang Dick, MD: The Federal Republic of West G e r m a n y has a highly effective standard of emergency medicine. The country is covered by a network of rescue areas supervised by rescue centers. Each rescue c e n t e r o w n s v a r i o u s r e s c u e ambulances, ranging from simple units staffed by emergency technicians to advanced physician-accompanied mobile ICUs. In addition, the country is covered by a helicopter service that can be s u m m o n e d by rescue centers or certain hospitals. The system ideally guarantees that e v e r y e m e r g e n c y p a t i e n t can be reached by an emergency ambulance within eight to ten minutes of the initial call. Two years ago, the German Association of Intensive Care and Emergency Medicine, together with the National Medical Council, developed m i n i m u m standards for emergency physicians; prior to certification in emergency medicine, a physician must spend at least one year in clinical practice (preferably in intensive care medicine) before application for certification. Further, the applicant must participate in an 80-credit-hour course in emergency medicine, including at least ten true emergency situations outside the hospital in an emergency ambulance under the supervision of an experienced emergency physician. Undergraduate education in emergency medicine in West Germany consists of two types of courses. A course in the preclinical part of the t r a i n i n g p e r i o d c o n s i s t s of eight credit hours, to be taken either at the university, the Red Cross, or at similar institutions. The National Resuscitation Council recently developed a course model for obtaining a driver's license, and this first course of prec l i n i c a l e m e r g e n c y m e d i c i n e is taught to medical students within this course framework. Thus, its quality is approximately equal to that of a required course for a driver's license. Part 1 of this program consists of eight hours of first aid training, part 2 consists of 16 hours of training in CPR, and a final six-hour refresher course focuses again on Annals of Emergency Medicine

CPR. This concept has not been officially accepted by the federal government but has been recommended by the National Resuscitation Council, all rescue organizations, and the German army. The second course is taken after completion of the first third of the u n d e r g r a d u a t e medical e d u c a t i o n program. It consists of weekly lectures over 12 weeks and is a 30credit-hour course that provides the undergraduate with practical knowledge in basic and advanced life support measures. It covers clinical assessment and restoration of vital functions; acute respiratory disturbances; acute cardiocirculatory dist u r b a n c e s ; a s s e s s m e n t of c o m a ; acute central nervous system disturbances; burns; near-drowning; polytrauma; and review of e m e r g e n c y drugs, apparatuses, and devices. At the end of the course, the student must pass both written and oral exa m i n a t i o n s c o v e r i n g a c u t e lifethreatening presentations and basic principles of anesthesiology and intensive care medicine. The complete program on paper appears to be quite adequate. In practice, lecture halls are overcrowded, and courses are carried out in substandard conditions. We train 500 students each year in e m e r g e n c y medicine in our university and run four courses a week. Hence, students receive i n s t r u c t i o n with five students per lecturer; they are limited to course participation only once during the first half of the semester and once again in the last half of the semester. This process is time intensive for our department; six faculty conduct this practical training and examination in emergency medicine daily. There is great interest in extending the present course from four hours per semester per student to 30 hours, but this was rejected by the federal administration due to lack of personnel and financial resources. The first examination at the end of the preclinical period concentrates on physics, chemistry, biology, psy i chology, physiology, biochemistry, and anatomy, but does not test emergency medicine content. The first part of the clinical examination does include q u e s t i o n s on e m e r g e n c y medicine. Without further training in emergency medicine, the student must take the final part of the examinations after internship, but receives 1156/133

UNDERGRADUATE EDUCATION Binder et al

training in some aspects of emergency medicine only if the program includes an elective in anesthesiology. Eighteen months of training in "practical medicine" was added to the postgraduate curriculum, but no structure for the 18-month training period has been developed yet due to a lack of training venues. Thus, only those physicians with anesthesiology training have obtained experience in emergency medicine during their practical studies. Medical educators in West Germany from all specialties consider a training period of at least three months in practical emergency medicine compulsory for the intern in practical training to improve theoretical and practical knowledge of the subject. Unfortunately, this has not been implemented thus far. In West Germany, who contributes to undergraduate training in emergency medicine? Anesthesiology departments are responsible for the organization of all undergraduate training in emergency medicine because almost all emergency measures are part of the daily practical work of the anesthesiologist. Most universities have organized multidiscipline training programs consisting of surgery, cardiology, trauma surgery, neurosurgery, otolaryngology, maxillofacial surgery, and gynecology/obstetrics in addition to anesthesiology. The various specialties participate in the theoretical aspects of undergraduate education in emergency medicine. In contrast to the United States and other countries, emergency medicine is not considered a specialty in its own right in Germany. Other specialties teach emergency medicine as an integrated part of their own specialties and organize their own emergency medicine programs and undergraduate education in emergency medicine. The concept itself is extremely effective and demonstrated its value 15 years ago when only five medical students passed the basic course in first aid after eight practical lessons per semester. During the following first clinical course in emergency medicine, the students received an additional 30 hours of eff e c t i v e t r a i n i n g by s p e c i a l t y discipline in emergency medicine, and pass rates improved markedly. However, the exorbitant increase in the number of medical students and disastrous classroom conditions due to the lack of university resources 134/1157

have subsequently limited the effectiveness of this concept. There is an urgent need for a standardized examination in emergency medicine at the undergraduate level, subdivided into three parts that are compatible with our existing medical curriculum. Part 1 should cover the first preclinical training program in first aid, part 2 should cover the course in acute life-threatening situations and emergency medicine, and part 3 should cover emergency medicine as a substantial par t of the final medical examination at either the end of internship or physician-inpractical-training. Part 3 would require not only theoretical courses in emergency medicine for successful completion, but also practical experience during internship or physicianin-practical-training. The West G e r m a n c o n c e p t in emergency medical training could train students to pass such an examination if the course were intensified as previously described, if the hours in the clinical part of the undergraduate curriculum were raised from 30 to at least 40 to 50, if it were offered in small groups with ample practice time for psychomotor skills training on mannequins, and if a practice period of three to six months covering the entire spectrum of emergency medicine could be completed within either the year of internship or the 1 8 - m o n t h period of p h y s i c i a n - i n practical-training. If at completion of the undergraduate curriculum this properly trained physician underwent postgraduate training in emergency medicine, his qualifications as an e m e r g e n c y p h y s i c i a n ( f u l l y trained also as an anesthesiologist, internist, surgeon, pediatrician, etc) would be exemplary. Joseph Epstein, MD: The structure of medical education in Australia and New Zealand consists of a sixyear undergraduate medical curriculum that directly follows secondary education, followed by postgraduate education in emergency medicine. Our postgraduate emergency medical programs are as good as those anywhere; however, our undergraduate education programs in e m e r g e n c y medicine are of poor quality. Most of our undergraduate educational programs are divided into preclinical and clinical halves that have increasingly overlapped as medical education revisions have been instituted. Annals of Emergency Medicine

In Australia and New Zealand, a total of 5,000 hours of undergraduate curriculum time is available; 60% of that time consists of classroom instruction and 40% consists of selflearning activities. Because of our recent colonial past, medical schools were previously accredited by the general medical council in the United Kingdom. The Australian medical council was recently established and is now in the process of accrediting medical schools. In their admission statement for the accreditation process, there is no mention of emergency medicine as such. However, the statement does mention the need for curricula designed to develop professional skills for dealing with common medical emergencies and for performing simple and practical clinical procedures. From the Australasian perspective, the e m p h a s i s of these panelists, while very interesting, is slightly awry. Considering the issue of the role of emergency medicine in the general professional education of the physician (ie, in the training of the nonemergency medicine specialist), our bias is that greater emphasis should be placed on expanding emergency medical education in postgraduate training than in the undergraduate curriculum. We believe that the educational experience that occurs in a physician's postgraduate training program and first years of practice has a greater effect on that physician's standard and style of practice than does the undergraduate educational program. The gains from increasing the presence of emergency medicine in the undergraduate curriculum are therefore not derived from c o n t r i b u t i o n to the standard of practice of medicine in most countries. They are instead derived from the establishment of a territory for e m e r g e n c y medicine in both the undergraduate curriculum and educational institution, and from improving r e c r u i t m e n t of quality medical students to the specialty of emergency medicine. We have a long, long way to go. The teaching of emergency medicine to undergraduates relates to our professional respectability, which in the end relates to the intellectual respectability of emergency medicine. The prestige of emergency medicine subsequently rests on its intellectual respectability compared with that of 19:10 October 1990

other specialties. In Australia and New Zealand, emergency medicine h a s a c h i e v e d a m e a s u r e of p r o f e s sional respect and prestige, but it m u s t i m p r o v e i t s t e a c h i n g a n d presence in the undergraduate curricul u m a n d i t s s t a n d i n g i n a c a d e m i c in-

stitutions by meaningful participat i o n o n t h e f r o n t i e r s of i n t e l l e c t u a l work.

REFERENCES 1. Binder LS, Scragg WH, Chappel JA, et al: Augmentation of the critical care data base of

junior medical students with an emergency medical lecture curriculum: A controlled study. l Emerg Med 1990;8:211-214. 2. Sanders AB, Criss E, Witzke D, et ah Survey of undergraduate emergency medical education in the United States. Ann Emerg Med 1986; 15:1-5.

See r e l a t e d e d i t o r i a l s , p 1187-1189.

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Undergraduate education in emergency medicine.

CONCEPTS, COMPONENTS & CONFIGURATIONS education Undergraduate Education in Emergency Medicine [Binder L, Emerrnan C, Tachakra S, Dick W, Epstein J: U...
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