Prehospital Emergency Care
ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20
Development of an EMS Curriculum Jane H. Brice MD, MPH, Debra G. Perina MD, J. Marc Liu MD, MPH, Darren A. Braude MD, MPH, Kathy J. Rinnert MD, MPH & Russell D. MacDonald MD, MPH To cite this article: Jane H. Brice MD, MPH, Debra G. Perina MD, J. Marc Liu MD, MPH, Darren A. Braude MD, MPH, Kathy J. Rinnert MD, MPH & Russell D. MacDonald MD, MPH (2014) Development of an EMS Curriculum, Prehospital Emergency Care, 18:1, 98-105 To link to this article: http://dx.doi.org/10.3109/10903127.2013.836265
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EDUCATION AND PRACTICE DEVELOPMENT OF AN EMS CURRICULUM Downloaded by [Nanyang Technological University] at 18:58 06 November 2015
Jane H. Brice, MD, MPH, Debra G. Perina, MD, J. Marc Liu, MD, MPH, Darren A. Braude, MD, MPH, Kathy J. Rinnert, MD, MPH, Russell D. MacDonald, MD, MPH ABSTRACT
tation methods can include simulation, observations, didactics, and experiential elements. Evaluation and outcomes assessment methods can include direct observation of patient assessment and treatment skills, structured patient simulations, 360◦ feedback, written and oral testing, and retrospective chart reviews. This paper describes a curriculum that is congruent with the current EMS core content, as well as providing a 12-month format to deploy the curriculum in an EMS fellowship program. Key words: curriculum; education; emergency medical services; fellowships and scholarships
Emergency medical services (EMS) became an American Board of Medical Specialties (ABMS) approved subspecialty of emergency medicine in September 2010. Achieving specialty or subspecialty recognition in an area of medical practice requires a unique body of knowledge, a scientific basis for the practice, a significant number of physicians who dedicate a portion of their practice to the area, and a sufficient number of fellowship programs. To prepare EMS fellows for successful completion of fellowship training, a lifetime of subspecialty practice, and certification examination, a formalized structured fellowship curriculum is necessary. A functional curriculum is one that takes the entire body of knowledge necessary to appropriately practice in the identified area and codifies it into a training blueprint to ensure that all of the items are covered over the prescribed training period. A curriculum can be as detailed as desired but typically all major headings and subheadings of the core content are identified and addressed. Common curricular components, specific to each area of the core content, include goals and objectives, implementation methods, evaluation, and outcomes assessment methods. Implemen-
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INTRODUCTION Emergency medical services (EMS) became an American Board of Medical Specialties (ABMS) approved subspecialty of emergency medicine in September 2010.1 While the American Board of Emergency Medicine (ABEM) is the parent board, certification is open to graduates of Accreditation Council for Graduate Medical Education (ACGME) approved residency programs in any specialty.2 The subspecialty of EMS is intended to improve patient safety and enhance the quality of emergency medical care provided to patients in the prehospital environment, to facilitate integration of prehospital patient treatment into the continuum of patient care, and to standardize physician training and qualifications for EMS practice.3 The growth and development of EMS as a medical subspecialty does not end with ACGME approval. Much work remains to be done prior to awarding the first board certificates and maturing EMS as a subspecialty. Taking the next step toward maturation of the subspecialty, ABEM established the EMS Examination Task Force in February 2011 to complete two tasks. The first task was to define the practice of EMS medicine, which was accomplished with the July 2012 publication of the Core Content of EMS Medicine.3 The second task was to develop the test bank of questions for use on the certification examination; this work is ongoing. While the core content defines the “training
Received April 8, 2013 from the Department of Emergency Medicine, The University of North Carolina School of Medicine, Chapel Hill, North Carolina (JHB), Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia (DGP), Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (JML), Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico (DAB), Division of Emergency Medicine, Department of Surgery, University of Texas Southwestern, Dallas, Texas (KJR), Department of Medicine, University of Toronto, Toronto, Ontario, Canada. Revision received June 23, 2103; accepted for publication July 12, 2013. We thank David Cone, MD, for his thoughtful and careful review of the manuscript. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Address correspondence to Jane H. Brice, MD, MPH, Professor, Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC 27599-7594, USA. e-mail: [email protected] doi: 10.3109/10903127.2013.836265
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parameters, resources, and knowledge of the treatment of prehospital patients necessary to practice EMS medicine,”3 it does not provide guidance on how this knowledge might be delivered to a fellow during training or on how to evaluate a fellow’s performance; a curriculum provides this guidance. The purpose of this paper is to discuss the development of an EMS fellowship curriculum and to provide an example of a curriculum sufficient to satisfy the core content material. It should be noted that the term “curriculum” may be defined in many ways. Utilizing Kern’s model of curriculum development, we also embrace his definition of curriculum: “a planned educational experience.”4 While the strictest definition of curriculum would incorporate elements such as instructional time frames and actual teaching materials, in this article, we present this curriculum as a planned educational experience which provides a detailed common structure mapping the EMS core content to core competencies, delivery methodology, and evaluative methods. The educational framework suggested here can then be individualized by EMS programs for their specific needs.
ACHIEVING SUBSPECIALTY RECOGNITION FOR EMS MEDICINE Achieving specialty or subspecialty recognition in an area of medical practice requires a unique body of knowledge, a scientific basis for the practice, a significant number of physicians who dedicate a portion of their practice to the area, and a sufficient number of fellowship programs. Furthermore, fellowship programs should be standardized and deploy curricula based on the core content knowledge for the identified area. Prior to subspecialty recognition from ABMS, a degree of uniformity already existed among fellowship training programs, and a suggested curriculum was integrated into training, but to various degrees.5–8 With subspecialty recognition, two major milestones are approaching: the first fellowships were accredited by the ACGME in February 2013, and graduates will sit for the first board certification examination in October 2013. To prepare EMS fellows for successful completion of fellowship training, a lifetime of subspecialty practice, and certification examination, a formalized structured fellowship curriculum is necessary. This curriculum must cover the entirety of the EMS core content. Since the EMS core content will serve as the blueprint for the examination, a curriculum that is based in and reflects the core content is both desirable and necessary.3 The American Board of Emergency Medicine makes public the core content basis for its examinations, including the weighting of the areas in that core content.
For the practice of emergency medicine, this information is updated and published every two years. With the recent publication of the Core Content of EMS, our work presented here is designed to convey the totality of EMS practice to assist program directors and others in understanding what fellowship programs should address to ensure fellows are exposed to the information and acquire the knowledge necessary for success in specialty practice and the examination. We hope this framework will be a guide to assist fellowship program directors in incorporating the entire core content into their training programs to promote the growth of their fellows, fellowships, and the specialty as a whole.
CURRICULUM DEVELOPMENT Historical Foundation for the EMS Curriculum It is difficult to trace the precise historical origin of an educational curriculum for EMS physicians but the roots likely stem from the training given to new medical directors in EMS systems established throughout the country during the 1970s and 1980s. Most original curricula were developed in emergency medicine residency programs, where basic knowledge of EMS was taught to emergency medicine residents. Though the exact “birth” of a fellowship EMS curriculum is unknown, there are several notable milestones that are well documented. As the science and practice of EMS matured, many recognized the need for formalized, dedicated training for EMS physicians. The first EMS fellowship was founded in 1977–78 at the Maryland Institute for EMS Systems (MIEMSS).9 As emergency medicine residency training became more widespread, various programs created EMS curricula for resident use. The earliest reference in published literature of an educational curriculum for physicians occurred in 1980, with an article describing a general EMS education for emergency medicine residents.5 In the late 1980s and early 1990s, several national medical organizations began to codify an EMS curriculum in an effort to achieve the designation of EMS as a recognized medical subspecialty. These efforts were aided by formalized courses and grant mechanisms, such as the American College of Emergency Physicians (ACEP) base station course, the National Association of EMS Physicians (NAEMSP) medical director’s course, and the Society for Academic Emergency Medicine/Physio-Control EMS Research Fellowship Grant, which was first offered in 1990.10 Representatives from ABEM, ACEP, NAEMSP, Council of Emergency Medicine Residency Directors (CORD), Emergency Medicine Residents Association (EMRA), and Society for Academic Emergency Medicine (SAEM) collaborated in defining the unique knowledge and
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scope of practice of an EMS physician. Although this initial attempt to obtain subspecialty designation was unsuccessful, the project led to the first published guidelines for EMS fellowship training. Subsequently, the first model EMS core content and curriculum based on these guidelines was published in 1994.6–8 Over the next decade, the number of EMS fellowship programs grew fairly rapidly. Each program adapted this curriculum according to its system resources and capabilities. As the science of EMS medicine matured, further standardization in EMS fellowship training was again proposed and national efforts to achieve ABMS recognition of EMS as an approved medical subspecialty were rekindled. In 2008, a task force was assembled jointly by NAEMSP and the ACEP EMS committee to explore the development of a new application for EMS subspecialty recognition. This task force asked NAEMSP to create a workgroup to update the 1994 core content document. This revised core content would serve as the basis for the scope of the practice of EMS medicine and become the springboard for creating a formal fellowship curriculum tied to the core content. The revised core content and a proposed curriculum were completed in January 2010, and were a major component in the application submitted by ABEM to ABMS to achieve formal subspecialty recognition.11
Assembly of Writing Team The curriculum used to support the successful ABMS application for board subspecialty recognition was written at the request of the EMS Subspecialty Task Force of the collaborating organizations. The team comprised established EMS fellowship directors and EMS fellowship graduates with an interest in medical education. Over a period of 6 months, the team worked directly with the task force to create a document that reflected the diverse practice elements of EMS medicine—clinical, administrative, research, and educational. The final document was 183 pages and detailed the goals, objectives, and evaluation of an EMS fellowship program and fellows. Since that time, the core content has been refined, streamlined, and published.3 The curriculum presented here reflects that new format and material and is written by the original members of the task force writing team with the addition of other EMS experts.
Curriculum Concepts A functional curriculum is one that takes the entire body of knowledge necessary to appropriately practice in the identified area and codifies it into a training blueprint to ensure that all of the items are covered over the prescribed training period. The body of knowledge, commonly called a core content, is deter-
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mined through a practice analysis of the area along with validation by a panel of experts. This is the process undertaken by the ABEM EMS examination task force to develop the core content. Typically, the core content is revised every few years to ensure it is concurrent and relevant. The EMS core content was last revised in the fall of 2011. This paper describes an EMS curriculum (Appendix 1, available online), which is congruent with the current core content, and provides a 12-month format to deploy the curriculum in an EMS fellowship program (Appendix 2, available online). A curriculum can be as detailed as desired but typically all major headings and subheadings of the core content are identified and addressed. Common curricular components, specific to each area of the core content, include goals and objectives, implementation methods, evaluation, and outcomes assessment methods. Implementation methods can include simulation, observations, didactics, and experiential elements. Evaluation and outcomes assessment methods can include direct observation of patient assessment and treatment skills, structured patient simulations, 360◦ feedback, written and oral testing, and retrospective chart reviews.
Elements of a Curriculum For those trying to develop an EMS curriculum that is specific to their locale and institution, it is highly recommended that an educational consultant or curricular expert be involved in the curriculum creation and design. Failing that, EMS fellowship directors should consult curriculum development texts for advice and counsel on the structure and elements of a curriculum. Texts such as Curriculum Development for Medical Education by Kern, Thomas, and Hughes and Practical Guide to the Evaluation of Clinical Competence by Holmboe and Hawkins can provide invaluable direction on how to create a practical and educationally sound curriculum document.12,13 In the next section, we provide an overview and synopsis of curriculum structure and elements. Our effort is not meant to be all-encompassing but rather to provide a brief overview of curricular structure, which should spur an EMS fellowship director to seek more information and substance.
Overall Educational Goal The first, and probably most important, element of a curriculum is the overall educational goal. Goals are distinctly different from objectives in that goals are broad and overarching intentions of the curriculum, whereas objectives are specific and measureable activities or behaviors. When establishing the program goals, it is critical to remember the essential outcomes of the EMS fellowship, which are to prepare a
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candidate to 1) become a competent and professional EMS physician and 2) successfully pass the EMS subspecialty board exam. Once established, these goals and objectives drive the curricular content, learning methods, and evaluative techniques. The goal of the EMS curriculum is to prepare the fellow to both independently provide patient care as well as manage other EMS providers to ensure competent, patient-centered medical care in the out-of-hospital environment. Because this curriculum encompasses the entire body of knowledge (i.e., the EMS Core Content), it is presented in a sectional format that addresses each distinct element of EMS practice—clinical, administrative, research, and educational. Individual sections should each have broad, overarching goals as well as specific, measurable objectives relative to the material contained within that section.
Objectives Objectives are, as mentioned earlier, specific and measureable. A common mistake in writing objectives is the use of fuzzy verbs, such as “to know” or “to understand.” Measuring understanding can prove difficult. To be measureable, objectives should use action verbs attached to quantifiable aliquots of knowledge, skill, or performance. As an example: “at the conclusion of the fellowship, the EMS fellow will have demonstrated, at least once, the appropriate technique, as defined on a check sheet, for performing a cricothyroidotomy either in the field or in a simulated environment.” A fellowship director could attest whether or not the fellow had accomplished this objective at the conclusion of the section or the fellowship. The example above describes a procedural skill and it is easy to see how such an objective is specific and measureable. This is an example of a psychomotor objective. Not all EMS curriculum objectives fall into this category. In general, objectives can be divided into three major categories: learner, process, and patient outcome. In the case of the EMS curriculum, it might also be possible to add a fourth category: system outcome. Learner Objectives Learner objectives address components of the cognitive, affective, and psychomotor domains originally described by Bloom in 1956.14 Each of these domains is reflected in the ACGME core competencies found in the educational program requirements. Cognitive requirements are intended to impart knowledge. However, cognitive objectives embrace more than a simple recitation of facts. A continuum of cognitive advancement from the simple recitation of facts to complex problem-solving and clinical decision-making is reflected in the construct of cognitive objectives.
101 Writing objectives to encompass each facet of the path from recitation to problem-solving is difficult. Most curriculum planners write objectives at the highest level of cognitive functioning they want learners to attain, recognizing that there are many steps in the path to achieving this summative objective.15 Bloom suggested a hierarchy of cognitive objectives: recall, comprehension, application, analysis, synthesis, and evaluation.14 Anderson revised this hierarchy in 2001, creating three steps in the path (remember, understand, and apply) to achieve a plateau constructed of three equivalent capabilities (analyze, evaluate, and create).16,17 Whichever hierarchy one accepts, it is important to recognize the enabling objectives that allow a learner to achieve the highest plane of capability; a learner must understand before he or she can create. The affective domain encompasses attitudinal objectives, such as values, beliefs, or emotions. While difficult to measure, these objectives are reflected in ACGME core competencies, such as professionalism and interpersonal skills. Krathwohl suggests five hierarchical levels for the affective domain: receiving, responding, valuing, organizing, and characterizing.18 Receiving implies the learner is observing but not engaging, while responding moves the learner forward by encouraging a response to a stimulus. A learner at the valuing stage attaches meaning or value to a concept or object. Students at the organizing stage can create their own schema and once the characterizing stage has been reached, a student can change his or her behavior to create a characteristic such as compassion or integrity. As an example, an affective domain objective for EMS might be written as: “At the end of the fellowship, an EMS fellow will be able to identify his or her attitudes and beliefs regarding safety in the EMS environment and have discussed with the fellowship faculty how to incorporate these values into his or her EMS practice.” The psychomotor domain translates into skill or behavioral objectives. Several authors have suggested hierarchies for the psychomotor domain but most of these apply more to athletes than to physicians.19–21 George Miller, a psychologist, proposed a hierarchy for clinical psychomotor skills that, in some ways, mirrors the phrase “see one, do one, teach one.” He suggests that a learner needs to 1) have a foundational knowledge of the skill, 2) understand how to perform the skill, 3) demonstrate the skill, and, finally, 4) perform the skill in actual clinical practice.22 When writing psychomotor objectives, it is important to distinguish between skill objectives and behavioral objectives. Skill or competency objectives measure whether or not a learner can perform a skill correctly. Behavioral objectives, on the other hand, measure whether or not a learner incorporates the skill into continuing practice and uses it appropriately. Creating multidomain objectives allows a curriculum designer to incorporate
102 elements from several domains into a single objective measuring the full complement of a knowledge set.
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Process Objectives The implementation of the curriculum into practice is captured by process objectives. These objectives describe how students will engage with the curriculum. It is important when writing process outcomes to distinguish between individual and program process objectives. An example of an individual process objective is: “The fellow will participate in at least one root cause analysis of either a reported near-miss or an actual medication error committed in the prehospital environment.” A program process objective example is: “All fellows will participate in a critical incident stress debriefing prior to completion of the fellowship.” Process outcomes describe what the learner is expected to do within the curriculum as well as the degree of engagement expected from the student. Outcome Objectives Outcome objectives describe the effect of the curriculum on the health-care problem that the curriculum addresses, in this case care of the patient in the outof-hospital environment. Potential areas the curriculum may address include health, health care, and patient outcomes. An example of an outcome objective focused on patient outcomes might be: “All patients resuscitated from ventricular fibrillation arrest will be cooled prior to hospital arrival.” Outcome objectives may also focus on career outcomes of the fellow. As an example, “90% of fellowship graduates will practice in the out-of-hospital environment five years after successful completion of the fellowship.” System Objectives EMS is a system of care that incorporates providers from dispatch to first response to ground EMS and/or air medical services. An EMS fellow must be able to work within a system of care to affect the care delivered to the individual patient. It is, therefore, necessary to consider system objectives in this curriculum schema. System objectives encompass the hierarchical concepts of apprentice, manager, developer, and leader. A system objective example is: “The EMS fellow will demonstrate leadership by selection/appointment as an active member of a local health-care, hospital, or EMS administrative committee.” Writing, measuring, and validating an objective for each and every possible component of the curriculum would be exhaustive and counterproductive. The key to a successful curriculum is to create a manageable set of objectives that incorporate all the learner, process, outcome, and system objectives while focusing and
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prioritizing those facets that are essential to achieving the overall education goals of the fellowship.
METHODS OF DELIVERING CONTENT In general, delivery of educational content should follow three implementation strategies. First, there should be harmony between the defined objectives and the methods utilized to deliver the objectives. For example, it makes little sense to lecture for hours on a psychomotor skill when a simulation laboratory or supervised practice would integrate both the didactic and psychomotor components at the same time. Cognitive objectives lend themselves to didactic delivery methods, although facilitated case discussion may provide more opportunity for the learner to engage in the material. Second, the use of multiple educational delivery methods allows the learner to utilize the fullest complement of learning strategies, since every student will have a preferred learning style. Some students learn best by reading, others by doing, and still others by hearing or engaging in discussion. When there is an overreliance on one teaching strategy or when there is a miss-match between the education delivery model and the student’s preferred learning style, the learner becomes bored, disinterested, and perhaps even frustrated and disheartened. Creating a balance of teaching methods and diversifying the educational delivery strategy enhances the learning environment and leads to more successful delivery of content.23 Researchers at North Carolina State University have created an online assessment of student learning styles that can be accessed at no cost.24,25 Additionally, diversifying the educational delivery methods opens up opportunities for reinforcing the material being taught, promoting retention and enhancing application.26 Finally, it is important to choose delivery methods that are feasible within the constraints of available resources. Cost, faculty time, learner time, availability of clinical opportunity, and physical space should all be considered when developing a program’s delivery methods.26
Evaluative Methods Having invested time, energy, and money into developing and delivering a comprehensive curriculum, it is essential to equally invest in evaluative processes. The ultimate test of the EMS curriculum will lie in the pass rate of the board certification exam and in the successful EMS practice and career outcomes of EMS fellows. However, prior to releasing fellows to independent practice, programs must provide successive opportunities for fellows and their fellowship directors to assess knowledge and skill acquisition. The ACGME’s six core competencies provide a useful framework for planning evaluation (Table 1).2,27
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TABLE 1. Accreditation Council for Graduate Medical Education Core Competencies2 Medical knowledge—knowledge of basic and clinical sciences, application Interpersonal and communication skills Patient care Professionalism Practice-based learning and improvement—care of patient Systems-based practice—understanding of health care teams and systems
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Medical knowledge is perhaps the easiest competency to impart and test. Written testing, interactive discussion with fellowship directors, and fellow education offerings to field providers allow the evaluation of knowledge acquisition. Interpersonal communication is more difficult to evaluate and requires creative yet structured evaluation formats. Patient care evaluation may take several forms, including direct observation in the field, retrospective chart reviews, and evaluations from other observers. Professionalism includes clinical competence, communication and interpersonal skills, and ethical and legal understanding.28 It is important to obtain feedback from evaluators who directly observe professional behavior and may include persons such as paramedics, administrators, and patients. Practice-based learning and improvement requires the fellow to demonstrate the ability to evaluate his or her performance and to make selfcorrection. Self-assessments and formative plans for improvement allow the fellowship director to measure a fellow’s capacity for self-improvement and correction. Finally, systems-based practice is critical in EMS medicine—understanding of health-care teams and systems. A fellow’s ability to measure the effectiveness of an EMS system and to work effectively to improve systems of care can be measured in work products such as quality improvement plans and system plans. When evaluating an EMS fellow, it is important to recognize the level of learner proficiency and test to that level.27 Dreyfus has proposed a five-stage model of learning, progressing from novice to expertise29,30 (Table 2). In the early months of a fellowship, the fellow has little capacity or knowledge and should not be expected to demonstrate mastery. As the fellow progresses the evaluative process should progress, providing the fellow with consistent feedback and directive instruction. Methods of assessment are as diverse as the imagination of the evaluator. Traditional methods include written testing and the use of standardized patients. Observational evaluation using simulation is becoming a validated and valuable modality. Utilizing work product (educational plans, EMS system plans, qual-
TABLE 2. Dreyfus Levels of Professional Development30,35 Novice
Identifies and uses rules of thumb
Advanced beginner Competent Proficient Expert
Connects rules to the common aspects of the plan Is able to plan an approach and execute the plan Regularly uses evidence-based work and takes waste out of that work Can use intuition where empirical knowledge does not yet exist
ity assurance reports, research manuscripts) as part of the evaluation package allows the learner to create a portfolio of work useful in job applications. Direct observation of a fellow’s practice in the field is invaluable and is considered mandatory. However, other measures of clinical proficiency may be undertaken in chart reviews, practice audits, or chart-simulated recall in which the fellow and director engage in an oral review of a case.31 Both the director and the fellow benefit from 360-degree feedback using multiple sources of information, including nurses, paramedics, patients, family members, dispatchers, administrators, and the fellow himself.32
Periodic Evaluation In every fellowship, periodic evaluation should be built into the schedule. While the most attention on evaluations is focused on evaluation of the fellow, periodic evaluation of the faculty and the program itself are also essential. Each fellowship faculty member should have the opportunity to receive structured and formative evaluation allowing for professional growth and development on a regular basis. Additionally, all of the program components should be evaluated regularly by both fellows and faculty.
FOUNDATIONAL DOCUMENT FOR FELLOWSHIP TRAINING A curriculum is, in essence, a contract between learner and teacher. Serving as the foundational document for fellowship training, a curriculum provides a blueprint for the learner of the subject matter and content of the fellowship, as well as the depth and breadth of material to teach for the teacher. A curriculum is a reference document that should be reviewed, revised, and updated at regular intervals throughout the course of study, allowing learner and teacher to mark progress (or deficiencies). Finally, a curriculum is an evaluative document enabling learner and teacher to evaluate the mastery of fellowship content and readiness for independent practice.
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ACGME EMS FELLOWSHIP PROGRAM REQUIREMENTS The ACGME EMS Fellowship Program Requirements, the standard against which fellowship programs are judged for ACGME accreditation, have been finalized.2 The program requirements specifically do not dictate curriculum; they primarily discuss logistical concerns, such as site requirements, personnel (program director, other program faculty), evaluations, duty hours and supervision, and eligibility criteria for entering fellows. The program requirements do, however, specify that each EMS fellowship program must integrate the six ACGME competency areas into the curriculum to ensure that graduating fellows are competent in patient care, medical knowledge, practicebased learning and improvement, interpersonal and communication skills, professionalism, and systemsbased practice. There is also a requirement for fellow participation in scholarly activity, currently listed as at least one of “1) peer-reviewed funding and research, 2) publication of original research articles or review articles, or 3) presentations at local, regional, or national professional and scientific society meetings.”2 Fellowship programs will need to integrate this scholarly work into their curricula to ensure that graduates meet this requirement. Patient care competency includes both generalities (“evaluating and comprehensively treating acutely ill and injured patients in the prehospital setting”) and specifics. The latter includes a list of what the ACGME refers to as “key index procedures,” including participation in a mass casualty/disaster triage at an actual event or drill; participation in a sentinel event investigation; conduction of a quality management audit; development of a mass gathering medical plan and participation in its implementation; emergency medical services protocol development or revision; immobilization of the spine; immobilization of an injured extremity; management of a cardiac arrest in the prehospital setting; management of a compromised airway in the prehospital setting; and provision of direct medical oversight on-scene or by radio or phone. Fellowship programs should consider how they will ensure adequate field time and teaching to promote competency in these core prehospital care procedures and processes, through a curriculum that involves both didactic and experiential components. Medical knowledge competency similarly includes generalities (“clinical manifestations and management of acutely ill and injured patients in the prehospital environment”) and specifics (e.g., “disaster planning and response,” “principles of quality improvement and patient safety”), and the topics listed can be addressed through the current model curriculum, as based on the NAEMSP textbook.33
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Practice-based learning and improvement competency includes demonstrating critical assessment of medical literature and medical informatics as well as research-based skills. Fellowship programs will need curricular material on research and effective use of medical informatics. Interpersonal and communication skills competency mentions teaching techniques, along with such skills as working effectively as a member or leader of a team. This will need to be addressed through curricular materials that are not particularly EMS-specific. Similarly, the professionalism and systems-based practice competencies have no EMSspecific requirements; fellowship programs can look to curricular material from other programs, including core emergency medicine programs, for guidance. A final section of the competencies section of the ACGME EMS fellowship program requirements outlines other general content and skill areas related to EMS, including such items as provision of medical care in mass gatherings, disaster planning and response, and emergency communications center operations. Items in this section are addressed in the NAEMSP textbook; thus, it should be straightforward for fellowship programs to develop curricular materials for these areas.
FUTURE DIRECTIONS The curriculum presented with this paper is a living document. It is not the final word. As the practice of EMS medicine advances and matures, the core content and curriculum will grow and change as well. EMS leaders envision that the core content will be revised on a periodic basis; so, too, will the curriculum require periodic updating. Kern et al. said it best: “For a successful curriculum, curricular development never really ends. Rather curriculum evolves, based on evaluation results, changes in resources, changes in targeted learners, and changes in the material requiring mastery.”34
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Kern DE. Introduction. In: Kern DE, Thomas PA, Hughes MT, eds. Curriculum Development for Medical Education, 2nd ed. Baltimore: The Johns Hopkins University Press; 2009. Lowry J, Lauro AJ. A general EMS curriculum for residency training. Ann Emerg Med. 1980;9:250–2. Krohmer JR, Swor RA, Benson N, Meador SA, Davidson SJ. Prototype curriculum for a fellowship in emergency medical services. Prehosp Disaster Med. 1994;9:73–7. Krohmer JR, Swor RA, Benson N, Meador SA, Davidson SJ. Prototype core content for a fellowship in emergency medical services. Ann Emerg Med. 1994:23:109–14. Marx JA, SAEM Task Force and Board of Directors. SAEM emergency medical services fellowship guidelines. Acad Emerg Med. 1999;6:1069–70. Personal communication with Robert Swor, MD, March 22, 2012. Society for Academic Emergency Medicine. Society for Academic Emergency Medicine/Physio-Control EMS Research Fellowship Grant. www.saem.org/saem-foundation/grants/ grant-archives. Accessed June 23, 2013. Delbridge TR, Perina DG. Emergency medicine services: a journey to subspecialty. Prehosp Emerg Care. 2011;15(1):1–3 Kern DE, Thomas PA, Hughes MT, eds. Curriculum Development for Medical Education, 2nd ed. Baltimore: The Johns Hopkins University Press; 2009. Holmboe ES, Hawkins RE. Practical Guide to the Evaluation of Clinical Competence. Philadelphia, PA: Mosby; 2008. Bloom BS, Engelhart MD, Furst EJ, Hill WH, Krathwohl DR. Taxonomy of Educational Objectives: The Classification of Educational Goals; Handbook I: Cognitive Domain. New York: Longmans, Green; 1956. Thomas PA. Goals and objectives. In: Kern DE, Thomas PA, Hughes MT, eds. Curriculum Development for Medical Education, 2nd ed. Baltimore: The Johns Hopkins University Press; 2009. Anderson L, Krathwohl DA. Taxonomy for Learning, Teaching and Assessing: A Revision of Bloom’s Taxonomy of Educational Objectives. New York: Longman; 2001. Anderson LW, Krathwohl DR, Airasian PW, Cruikshank KA, Mayer RE, Pintrich PR, Raths J, Wittrock MC, eds. A Taxonomy for Learning, Teaching, and Assessing: A Revision of Bloom’s Taxonomy of Educational Objectives. New York: Allyn & Bacon; 2000. Krathwohl DR, Bloom BS, Masia BB. Taxonomy of Educational Objectives; The Classification of Educational Goals. Handbook II: The Affective Domain. New York: Longman, Green; 1964. Simpson EJ. The Classification of Educational Objectives in the Psychomotor Domain. Washington, DC: Gryphon House; 1972. Harrow AJ. A Taxonomy of the Psychomotor Domain. New York: David McKay Co.; 1972. Dave RH. Psychomotor levels. In: RJ. Armstrong, ed. Developing and Writing Educational Objectives. Tucson, AZ: Educational Innovators Press; 1970: 33–34.
22. Miller GE. The assessment of clinical skills/competence/ performance. Acad Med. 1990;65(9): s63–7. 23. Felder RM, Brent R. Understanding student differences. J Engr Educ. 2005;94(1):57–72. 24. Felder RM, Soloman BA. Index of learning styles. www4.ncsu. edu/unity/lockers/users/f/felder/public/ILSpage.html. Accessed June 23, 2013. 25. Soloman BA, Felder RM. Index of learning styles questionnaire. www.engr.ncsu.edu/learningstyles/ilsweb.html. Accessed June 23, 2013. 26. Hughes MT. Implementation. In: Kern DE, Thomas PA, Hughes MT, eds. Curriculum Development for Medical Education, 2nd ed. Baltimore: The Johns Hopkins University Press; 2009. 27. Norcini JJ, Holmboe ES, Hawkins RE. Evaluation challenges in the era of outcomes-based education. In: Holmboe ES, Hawkins RE, eds. Practical Guide to the Evaluation of Clinical Competence. Philadelphia, PA: Mosby; 2008. 28. Cooke M, Irby DM, O’Brien BC. Educating Physicians: A Call for Reform of Medical School and Residency. Stanford, CA: Josey-Bass Higher and Adult Education Series; 2010. 29. Dreyfus HL. On the Internet. Thinking in Action Series. New York: Routledge; 2001. 30. Dreyfus H, Dreyfus S. Mind over Medicine. New York: Free Press; 1982. 31. Holmboe ES. Practice audit, medical record review, and chartstimulated recall. In: Holmboe ES, Hawkins RE, eds. Practical Guide to the Evaluation of Clinical Competence. Philadelphia, PA: Mosby; 2008. 32. Lockyer JM, Clyman SG. Multisource feedback (360-degree evaluation). In: Holmboe ES, Hawkins RE, eds. Practical Guide to the Evaluation of Clinical Competence. Philadelphia, PA: Mosby; 2008. 33. Cone DC, O’Connor RE, Fowler RL, eds. Emergency Medical Services: Clinical Practice and Systems Oversight. Dubuque, IA: Kendall Hunt; 2009. 34. Kern DE. Overview: A six-step approach to curriculum development. In: Kern DE, Thomas PA, Hughes MT, eds. Curriculum Development for Medical Education, 2nd ed. Baltimore: The Johns Hopkins University Press; 2009 35. Ogrinc G, Headrick LA, Mutha S, Coleman MT, O’Donnell J, Miles PV. A framework for teaching medical students and residents about practice-based learning and improvement, synthesized from a literature review. Acad Med. 2003;78:748– 56.
SUPPLEMENTAL MATERIAL AVAILABLE ONLINE Appendix 1: Suggested Curriculum of EMS Medicine. Appendix 2: A 12-month Model Curriculum.
ISSN: 1090-3127 (Print) 1545-0066 (Online) Journal homepage: http://www.tandfonline.com/loi/ipec20
Development of an EMS Curriculum Jane H. Brice MD, MPH, Debra G. Perina MD, J. Marc Liu MD, MPH, Darren A. Braude MD, MPH, Kathy J. Rinnert MD, MPH & Russell D. MacDonald MD, MPH To cite this article: Jane H. Brice MD, MPH, Debra G. Perina MD, J. Marc Liu MD, MPH, Darren A. Braude MD, MPH, Kathy J. Rinnert MD, MPH & Russell D. MacDonald MD, MPH (2014) Development of an EMS Curriculum, Prehospital Emergency Care, 18:1, 98-105 To link to this article: http://dx.doi.org/10.3109/10903127.2013.836265
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Date: 06 November 2015, At: 18:58
EDUCATION AND PRACTICE DEVELOPMENT OF AN EMS CURRICULUM Downloaded by [Nanyang Technological University] at 18:58 06 November 2015
Jane H. Brice, MD, MPH, Debra G. Perina, MD, J. Marc Liu, MD, MPH, Darren A. Braude, MD, MPH, Kathy J. Rinnert, MD, MPH, Russell D. MacDonald, MD, MPH ABSTRACT
tation methods can include simulation, observations, didactics, and experiential elements. Evaluation and outcomes assessment methods can include direct observation of patient assessment and treatment skills, structured patient simulations, 360◦ feedback, written and oral testing, and retrospective chart reviews. This paper describes a curriculum that is congruent with the current EMS core content, as well as providing a 12-month format to deploy the curriculum in an EMS fellowship program. Key words: curriculum; education; emergency medical services; fellowships and scholarships
Emergency medical services (EMS) became an American Board of Medical Specialties (ABMS) approved subspecialty of emergency medicine in September 2010. Achieving specialty or subspecialty recognition in an area of medical practice requires a unique body of knowledge, a scientific basis for the practice, a significant number of physicians who dedicate a portion of their practice to the area, and a sufficient number of fellowship programs. To prepare EMS fellows for successful completion of fellowship training, a lifetime of subspecialty practice, and certification examination, a formalized structured fellowship curriculum is necessary. A functional curriculum is one that takes the entire body of knowledge necessary to appropriately practice in the identified area and codifies it into a training blueprint to ensure that all of the items are covered over the prescribed training period. A curriculum can be as detailed as desired but typically all major headings and subheadings of the core content are identified and addressed. Common curricular components, specific to each area of the core content, include goals and objectives, implementation methods, evaluation, and outcomes assessment methods. Implemen-
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INTRODUCTION Emergency medical services (EMS) became an American Board of Medical Specialties (ABMS) approved subspecialty of emergency medicine in September 2010.1 While the American Board of Emergency Medicine (ABEM) is the parent board, certification is open to graduates of Accreditation Council for Graduate Medical Education (ACGME) approved residency programs in any specialty.2 The subspecialty of EMS is intended to improve patient safety and enhance the quality of emergency medical care provided to patients in the prehospital environment, to facilitate integration of prehospital patient treatment into the continuum of patient care, and to standardize physician training and qualifications for EMS practice.3 The growth and development of EMS as a medical subspecialty does not end with ACGME approval. Much work remains to be done prior to awarding the first board certificates and maturing EMS as a subspecialty. Taking the next step toward maturation of the subspecialty, ABEM established the EMS Examination Task Force in February 2011 to complete two tasks. The first task was to define the practice of EMS medicine, which was accomplished with the July 2012 publication of the Core Content of EMS Medicine.3 The second task was to develop the test bank of questions for use on the certification examination; this work is ongoing. While the core content defines the “training
Received April 8, 2013 from the Department of Emergency Medicine, The University of North Carolina School of Medicine, Chapel Hill, North Carolina (JHB), Department of Emergency Medicine, University of Virginia, Charlottesville, Virginia (DGP), Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin (JML), Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico (DAB), Division of Emergency Medicine, Department of Surgery, University of Texas Southwestern, Dallas, Texas (KJR), Department of Medicine, University of Toronto, Toronto, Ontario, Canada. Revision received June 23, 2103; accepted for publication July 12, 2013. We thank David Cone, MD, for his thoughtful and careful review of the manuscript. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. Address correspondence to Jane H. Brice, MD, MPH, Professor, Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC 27599-7594, USA. e-mail: [email protected] doi: 10.3109/10903127.2013.836265
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parameters, resources, and knowledge of the treatment of prehospital patients necessary to practice EMS medicine,”3 it does not provide guidance on how this knowledge might be delivered to a fellow during training or on how to evaluate a fellow’s performance; a curriculum provides this guidance. The purpose of this paper is to discuss the development of an EMS fellowship curriculum and to provide an example of a curriculum sufficient to satisfy the core content material. It should be noted that the term “curriculum” may be defined in many ways. Utilizing Kern’s model of curriculum development, we also embrace his definition of curriculum: “a planned educational experience.”4 While the strictest definition of curriculum would incorporate elements such as instructional time frames and actual teaching materials, in this article, we present this curriculum as a planned educational experience which provides a detailed common structure mapping the EMS core content to core competencies, delivery methodology, and evaluative methods. The educational framework suggested here can then be individualized by EMS programs for their specific needs.
ACHIEVING SUBSPECIALTY RECOGNITION FOR EMS MEDICINE Achieving specialty or subspecialty recognition in an area of medical practice requires a unique body of knowledge, a scientific basis for the practice, a significant number of physicians who dedicate a portion of their practice to the area, and a sufficient number of fellowship programs. Furthermore, fellowship programs should be standardized and deploy curricula based on the core content knowledge for the identified area. Prior to subspecialty recognition from ABMS, a degree of uniformity already existed among fellowship training programs, and a suggested curriculum was integrated into training, but to various degrees.5–8 With subspecialty recognition, two major milestones are approaching: the first fellowships were accredited by the ACGME in February 2013, and graduates will sit for the first board certification examination in October 2013. To prepare EMS fellows for successful completion of fellowship training, a lifetime of subspecialty practice, and certification examination, a formalized structured fellowship curriculum is necessary. This curriculum must cover the entirety of the EMS core content. Since the EMS core content will serve as the blueprint for the examination, a curriculum that is based in and reflects the core content is both desirable and necessary.3 The American Board of Emergency Medicine makes public the core content basis for its examinations, including the weighting of the areas in that core content.
For the practice of emergency medicine, this information is updated and published every two years. With the recent publication of the Core Content of EMS, our work presented here is designed to convey the totality of EMS practice to assist program directors and others in understanding what fellowship programs should address to ensure fellows are exposed to the information and acquire the knowledge necessary for success in specialty practice and the examination. We hope this framework will be a guide to assist fellowship program directors in incorporating the entire core content into their training programs to promote the growth of their fellows, fellowships, and the specialty as a whole.
CURRICULUM DEVELOPMENT Historical Foundation for the EMS Curriculum It is difficult to trace the precise historical origin of an educational curriculum for EMS physicians but the roots likely stem from the training given to new medical directors in EMS systems established throughout the country during the 1970s and 1980s. Most original curricula were developed in emergency medicine residency programs, where basic knowledge of EMS was taught to emergency medicine residents. Though the exact “birth” of a fellowship EMS curriculum is unknown, there are several notable milestones that are well documented. As the science and practice of EMS matured, many recognized the need for formalized, dedicated training for EMS physicians. The first EMS fellowship was founded in 1977–78 at the Maryland Institute for EMS Systems (MIEMSS).9 As emergency medicine residency training became more widespread, various programs created EMS curricula for resident use. The earliest reference in published literature of an educational curriculum for physicians occurred in 1980, with an article describing a general EMS education for emergency medicine residents.5 In the late 1980s and early 1990s, several national medical organizations began to codify an EMS curriculum in an effort to achieve the designation of EMS as a recognized medical subspecialty. These efforts were aided by formalized courses and grant mechanisms, such as the American College of Emergency Physicians (ACEP) base station course, the National Association of EMS Physicians (NAEMSP) medical director’s course, and the Society for Academic Emergency Medicine/Physio-Control EMS Research Fellowship Grant, which was first offered in 1990.10 Representatives from ABEM, ACEP, NAEMSP, Council of Emergency Medicine Residency Directors (CORD), Emergency Medicine Residents Association (EMRA), and Society for Academic Emergency Medicine (SAEM) collaborated in defining the unique knowledge and
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scope of practice of an EMS physician. Although this initial attempt to obtain subspecialty designation was unsuccessful, the project led to the first published guidelines for EMS fellowship training. Subsequently, the first model EMS core content and curriculum based on these guidelines was published in 1994.6–8 Over the next decade, the number of EMS fellowship programs grew fairly rapidly. Each program adapted this curriculum according to its system resources and capabilities. As the science of EMS medicine matured, further standardization in EMS fellowship training was again proposed and national efforts to achieve ABMS recognition of EMS as an approved medical subspecialty were rekindled. In 2008, a task force was assembled jointly by NAEMSP and the ACEP EMS committee to explore the development of a new application for EMS subspecialty recognition. This task force asked NAEMSP to create a workgroup to update the 1994 core content document. This revised core content would serve as the basis for the scope of the practice of EMS medicine and become the springboard for creating a formal fellowship curriculum tied to the core content. The revised core content and a proposed curriculum were completed in January 2010, and were a major component in the application submitted by ABEM to ABMS to achieve formal subspecialty recognition.11
Assembly of Writing Team The curriculum used to support the successful ABMS application for board subspecialty recognition was written at the request of the EMS Subspecialty Task Force of the collaborating organizations. The team comprised established EMS fellowship directors and EMS fellowship graduates with an interest in medical education. Over a period of 6 months, the team worked directly with the task force to create a document that reflected the diverse practice elements of EMS medicine—clinical, administrative, research, and educational. The final document was 183 pages and detailed the goals, objectives, and evaluation of an EMS fellowship program and fellows. Since that time, the core content has been refined, streamlined, and published.3 The curriculum presented here reflects that new format and material and is written by the original members of the task force writing team with the addition of other EMS experts.
Curriculum Concepts A functional curriculum is one that takes the entire body of knowledge necessary to appropriately practice in the identified area and codifies it into a training blueprint to ensure that all of the items are covered over the prescribed training period. The body of knowledge, commonly called a core content, is deter-
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mined through a practice analysis of the area along with validation by a panel of experts. This is the process undertaken by the ABEM EMS examination task force to develop the core content. Typically, the core content is revised every few years to ensure it is concurrent and relevant. The EMS core content was last revised in the fall of 2011. This paper describes an EMS curriculum (Appendix 1, available online), which is congruent with the current core content, and provides a 12-month format to deploy the curriculum in an EMS fellowship program (Appendix 2, available online). A curriculum can be as detailed as desired but typically all major headings and subheadings of the core content are identified and addressed. Common curricular components, specific to each area of the core content, include goals and objectives, implementation methods, evaluation, and outcomes assessment methods. Implementation methods can include simulation, observations, didactics, and experiential elements. Evaluation and outcomes assessment methods can include direct observation of patient assessment and treatment skills, structured patient simulations, 360◦ feedback, written and oral testing, and retrospective chart reviews.
Elements of a Curriculum For those trying to develop an EMS curriculum that is specific to their locale and institution, it is highly recommended that an educational consultant or curricular expert be involved in the curriculum creation and design. Failing that, EMS fellowship directors should consult curriculum development texts for advice and counsel on the structure and elements of a curriculum. Texts such as Curriculum Development for Medical Education by Kern, Thomas, and Hughes and Practical Guide to the Evaluation of Clinical Competence by Holmboe and Hawkins can provide invaluable direction on how to create a practical and educationally sound curriculum document.12,13 In the next section, we provide an overview and synopsis of curriculum structure and elements. Our effort is not meant to be all-encompassing but rather to provide a brief overview of curricular structure, which should spur an EMS fellowship director to seek more information and substance.
Overall Educational Goal The first, and probably most important, element of a curriculum is the overall educational goal. Goals are distinctly different from objectives in that goals are broad and overarching intentions of the curriculum, whereas objectives are specific and measureable activities or behaviors. When establishing the program goals, it is critical to remember the essential outcomes of the EMS fellowship, which are to prepare a
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candidate to 1) become a competent and professional EMS physician and 2) successfully pass the EMS subspecialty board exam. Once established, these goals and objectives drive the curricular content, learning methods, and evaluative techniques. The goal of the EMS curriculum is to prepare the fellow to both independently provide patient care as well as manage other EMS providers to ensure competent, patient-centered medical care in the out-of-hospital environment. Because this curriculum encompasses the entire body of knowledge (i.e., the EMS Core Content), it is presented in a sectional format that addresses each distinct element of EMS practice—clinical, administrative, research, and educational. Individual sections should each have broad, overarching goals as well as specific, measurable objectives relative to the material contained within that section.
Objectives Objectives are, as mentioned earlier, specific and measureable. A common mistake in writing objectives is the use of fuzzy verbs, such as “to know” or “to understand.” Measuring understanding can prove difficult. To be measureable, objectives should use action verbs attached to quantifiable aliquots of knowledge, skill, or performance. As an example: “at the conclusion of the fellowship, the EMS fellow will have demonstrated, at least once, the appropriate technique, as defined on a check sheet, for performing a cricothyroidotomy either in the field or in a simulated environment.” A fellowship director could attest whether or not the fellow had accomplished this objective at the conclusion of the section or the fellowship. The example above describes a procedural skill and it is easy to see how such an objective is specific and measureable. This is an example of a psychomotor objective. Not all EMS curriculum objectives fall into this category. In general, objectives can be divided into three major categories: learner, process, and patient outcome. In the case of the EMS curriculum, it might also be possible to add a fourth category: system outcome. Learner Objectives Learner objectives address components of the cognitive, affective, and psychomotor domains originally described by Bloom in 1956.14 Each of these domains is reflected in the ACGME core competencies found in the educational program requirements. Cognitive requirements are intended to impart knowledge. However, cognitive objectives embrace more than a simple recitation of facts. A continuum of cognitive advancement from the simple recitation of facts to complex problem-solving and clinical decision-making is reflected in the construct of cognitive objectives.
101 Writing objectives to encompass each facet of the path from recitation to problem-solving is difficult. Most curriculum planners write objectives at the highest level of cognitive functioning they want learners to attain, recognizing that there are many steps in the path to achieving this summative objective.15 Bloom suggested a hierarchy of cognitive objectives: recall, comprehension, application, analysis, synthesis, and evaluation.14 Anderson revised this hierarchy in 2001, creating three steps in the path (remember, understand, and apply) to achieve a plateau constructed of three equivalent capabilities (analyze, evaluate, and create).16,17 Whichever hierarchy one accepts, it is important to recognize the enabling objectives that allow a learner to achieve the highest plane of capability; a learner must understand before he or she can create. The affective domain encompasses attitudinal objectives, such as values, beliefs, or emotions. While difficult to measure, these objectives are reflected in ACGME core competencies, such as professionalism and interpersonal skills. Krathwohl suggests five hierarchical levels for the affective domain: receiving, responding, valuing, organizing, and characterizing.18 Receiving implies the learner is observing but not engaging, while responding moves the learner forward by encouraging a response to a stimulus. A learner at the valuing stage attaches meaning or value to a concept or object. Students at the organizing stage can create their own schema and once the characterizing stage has been reached, a student can change his or her behavior to create a characteristic such as compassion or integrity. As an example, an affective domain objective for EMS might be written as: “At the end of the fellowship, an EMS fellow will be able to identify his or her attitudes and beliefs regarding safety in the EMS environment and have discussed with the fellowship faculty how to incorporate these values into his or her EMS practice.” The psychomotor domain translates into skill or behavioral objectives. Several authors have suggested hierarchies for the psychomotor domain but most of these apply more to athletes than to physicians.19–21 George Miller, a psychologist, proposed a hierarchy for clinical psychomotor skills that, in some ways, mirrors the phrase “see one, do one, teach one.” He suggests that a learner needs to 1) have a foundational knowledge of the skill, 2) understand how to perform the skill, 3) demonstrate the skill, and, finally, 4) perform the skill in actual clinical practice.22 When writing psychomotor objectives, it is important to distinguish between skill objectives and behavioral objectives. Skill or competency objectives measure whether or not a learner can perform a skill correctly. Behavioral objectives, on the other hand, measure whether or not a learner incorporates the skill into continuing practice and uses it appropriately. Creating multidomain objectives allows a curriculum designer to incorporate
102 elements from several domains into a single objective measuring the full complement of a knowledge set.
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Process Objectives The implementation of the curriculum into practice is captured by process objectives. These objectives describe how students will engage with the curriculum. It is important when writing process outcomes to distinguish between individual and program process objectives. An example of an individual process objective is: “The fellow will participate in at least one root cause analysis of either a reported near-miss or an actual medication error committed in the prehospital environment.” A program process objective example is: “All fellows will participate in a critical incident stress debriefing prior to completion of the fellowship.” Process outcomes describe what the learner is expected to do within the curriculum as well as the degree of engagement expected from the student. Outcome Objectives Outcome objectives describe the effect of the curriculum on the health-care problem that the curriculum addresses, in this case care of the patient in the outof-hospital environment. Potential areas the curriculum may address include health, health care, and patient outcomes. An example of an outcome objective focused on patient outcomes might be: “All patients resuscitated from ventricular fibrillation arrest will be cooled prior to hospital arrival.” Outcome objectives may also focus on career outcomes of the fellow. As an example, “90% of fellowship graduates will practice in the out-of-hospital environment five years after successful completion of the fellowship.” System Objectives EMS is a system of care that incorporates providers from dispatch to first response to ground EMS and/or air medical services. An EMS fellow must be able to work within a system of care to affect the care delivered to the individual patient. It is, therefore, necessary to consider system objectives in this curriculum schema. System objectives encompass the hierarchical concepts of apprentice, manager, developer, and leader. A system objective example is: “The EMS fellow will demonstrate leadership by selection/appointment as an active member of a local health-care, hospital, or EMS administrative committee.” Writing, measuring, and validating an objective for each and every possible component of the curriculum would be exhaustive and counterproductive. The key to a successful curriculum is to create a manageable set of objectives that incorporate all the learner, process, outcome, and system objectives while focusing and
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prioritizing those facets that are essential to achieving the overall education goals of the fellowship.
METHODS OF DELIVERING CONTENT In general, delivery of educational content should follow three implementation strategies. First, there should be harmony between the defined objectives and the methods utilized to deliver the objectives. For example, it makes little sense to lecture for hours on a psychomotor skill when a simulation laboratory or supervised practice would integrate both the didactic and psychomotor components at the same time. Cognitive objectives lend themselves to didactic delivery methods, although facilitated case discussion may provide more opportunity for the learner to engage in the material. Second, the use of multiple educational delivery methods allows the learner to utilize the fullest complement of learning strategies, since every student will have a preferred learning style. Some students learn best by reading, others by doing, and still others by hearing or engaging in discussion. When there is an overreliance on one teaching strategy or when there is a miss-match between the education delivery model and the student’s preferred learning style, the learner becomes bored, disinterested, and perhaps even frustrated and disheartened. Creating a balance of teaching methods and diversifying the educational delivery strategy enhances the learning environment and leads to more successful delivery of content.23 Researchers at North Carolina State University have created an online assessment of student learning styles that can be accessed at no cost.24,25 Additionally, diversifying the educational delivery methods opens up opportunities for reinforcing the material being taught, promoting retention and enhancing application.26 Finally, it is important to choose delivery methods that are feasible within the constraints of available resources. Cost, faculty time, learner time, availability of clinical opportunity, and physical space should all be considered when developing a program’s delivery methods.26
Evaluative Methods Having invested time, energy, and money into developing and delivering a comprehensive curriculum, it is essential to equally invest in evaluative processes. The ultimate test of the EMS curriculum will lie in the pass rate of the board certification exam and in the successful EMS practice and career outcomes of EMS fellows. However, prior to releasing fellows to independent practice, programs must provide successive opportunities for fellows and their fellowship directors to assess knowledge and skill acquisition. The ACGME’s six core competencies provide a useful framework for planning evaluation (Table 1).2,27
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TABLE 1. Accreditation Council for Graduate Medical Education Core Competencies2 Medical knowledge—knowledge of basic and clinical sciences, application Interpersonal and communication skills Patient care Professionalism Practice-based learning and improvement—care of patient Systems-based practice—understanding of health care teams and systems
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Medical knowledge is perhaps the easiest competency to impart and test. Written testing, interactive discussion with fellowship directors, and fellow education offerings to field providers allow the evaluation of knowledge acquisition. Interpersonal communication is more difficult to evaluate and requires creative yet structured evaluation formats. Patient care evaluation may take several forms, including direct observation in the field, retrospective chart reviews, and evaluations from other observers. Professionalism includes clinical competence, communication and interpersonal skills, and ethical and legal understanding.28 It is important to obtain feedback from evaluators who directly observe professional behavior and may include persons such as paramedics, administrators, and patients. Practice-based learning and improvement requires the fellow to demonstrate the ability to evaluate his or her performance and to make selfcorrection. Self-assessments and formative plans for improvement allow the fellowship director to measure a fellow’s capacity for self-improvement and correction. Finally, systems-based practice is critical in EMS medicine—understanding of health-care teams and systems. A fellow’s ability to measure the effectiveness of an EMS system and to work effectively to improve systems of care can be measured in work products such as quality improvement plans and system plans. When evaluating an EMS fellow, it is important to recognize the level of learner proficiency and test to that level.27 Dreyfus has proposed a five-stage model of learning, progressing from novice to expertise29,30 (Table 2). In the early months of a fellowship, the fellow has little capacity or knowledge and should not be expected to demonstrate mastery. As the fellow progresses the evaluative process should progress, providing the fellow with consistent feedback and directive instruction. Methods of assessment are as diverse as the imagination of the evaluator. Traditional methods include written testing and the use of standardized patients. Observational evaluation using simulation is becoming a validated and valuable modality. Utilizing work product (educational plans, EMS system plans, qual-
TABLE 2. Dreyfus Levels of Professional Development30,35 Novice
Identifies and uses rules of thumb
Advanced beginner Competent Proficient Expert
Connects rules to the common aspects of the plan Is able to plan an approach and execute the plan Regularly uses evidence-based work and takes waste out of that work Can use intuition where empirical knowledge does not yet exist
ity assurance reports, research manuscripts) as part of the evaluation package allows the learner to create a portfolio of work useful in job applications. Direct observation of a fellow’s practice in the field is invaluable and is considered mandatory. However, other measures of clinical proficiency may be undertaken in chart reviews, practice audits, or chart-simulated recall in which the fellow and director engage in an oral review of a case.31 Both the director and the fellow benefit from 360-degree feedback using multiple sources of information, including nurses, paramedics, patients, family members, dispatchers, administrators, and the fellow himself.32
Periodic Evaluation In every fellowship, periodic evaluation should be built into the schedule. While the most attention on evaluations is focused on evaluation of the fellow, periodic evaluation of the faculty and the program itself are also essential. Each fellowship faculty member should have the opportunity to receive structured and formative evaluation allowing for professional growth and development on a regular basis. Additionally, all of the program components should be evaluated regularly by both fellows and faculty.
FOUNDATIONAL DOCUMENT FOR FELLOWSHIP TRAINING A curriculum is, in essence, a contract between learner and teacher. Serving as the foundational document for fellowship training, a curriculum provides a blueprint for the learner of the subject matter and content of the fellowship, as well as the depth and breadth of material to teach for the teacher. A curriculum is a reference document that should be reviewed, revised, and updated at regular intervals throughout the course of study, allowing learner and teacher to mark progress (or deficiencies). Finally, a curriculum is an evaluative document enabling learner and teacher to evaluate the mastery of fellowship content and readiness for independent practice.
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ACGME EMS FELLOWSHIP PROGRAM REQUIREMENTS The ACGME EMS Fellowship Program Requirements, the standard against which fellowship programs are judged for ACGME accreditation, have been finalized.2 The program requirements specifically do not dictate curriculum; they primarily discuss logistical concerns, such as site requirements, personnel (program director, other program faculty), evaluations, duty hours and supervision, and eligibility criteria for entering fellows. The program requirements do, however, specify that each EMS fellowship program must integrate the six ACGME competency areas into the curriculum to ensure that graduating fellows are competent in patient care, medical knowledge, practicebased learning and improvement, interpersonal and communication skills, professionalism, and systemsbased practice. There is also a requirement for fellow participation in scholarly activity, currently listed as at least one of “1) peer-reviewed funding and research, 2) publication of original research articles or review articles, or 3) presentations at local, regional, or national professional and scientific society meetings.”2 Fellowship programs will need to integrate this scholarly work into their curricula to ensure that graduates meet this requirement. Patient care competency includes both generalities (“evaluating and comprehensively treating acutely ill and injured patients in the prehospital setting”) and specifics. The latter includes a list of what the ACGME refers to as “key index procedures,” including participation in a mass casualty/disaster triage at an actual event or drill; participation in a sentinel event investigation; conduction of a quality management audit; development of a mass gathering medical plan and participation in its implementation; emergency medical services protocol development or revision; immobilization of the spine; immobilization of an injured extremity; management of a cardiac arrest in the prehospital setting; management of a compromised airway in the prehospital setting; and provision of direct medical oversight on-scene or by radio or phone. Fellowship programs should consider how they will ensure adequate field time and teaching to promote competency in these core prehospital care procedures and processes, through a curriculum that involves both didactic and experiential components. Medical knowledge competency similarly includes generalities (“clinical manifestations and management of acutely ill and injured patients in the prehospital environment”) and specifics (e.g., “disaster planning and response,” “principles of quality improvement and patient safety”), and the topics listed can be addressed through the current model curriculum, as based on the NAEMSP textbook.33
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Practice-based learning and improvement competency includes demonstrating critical assessment of medical literature and medical informatics as well as research-based skills. Fellowship programs will need curricular material on research and effective use of medical informatics. Interpersonal and communication skills competency mentions teaching techniques, along with such skills as working effectively as a member or leader of a team. This will need to be addressed through curricular materials that are not particularly EMS-specific. Similarly, the professionalism and systems-based practice competencies have no EMSspecific requirements; fellowship programs can look to curricular material from other programs, including core emergency medicine programs, for guidance. A final section of the competencies section of the ACGME EMS fellowship program requirements outlines other general content and skill areas related to EMS, including such items as provision of medical care in mass gatherings, disaster planning and response, and emergency communications center operations. Items in this section are addressed in the NAEMSP textbook; thus, it should be straightforward for fellowship programs to develop curricular materials for these areas.
FUTURE DIRECTIONS The curriculum presented with this paper is a living document. It is not the final word. As the practice of EMS medicine advances and matures, the core content and curriculum will grow and change as well. EMS leaders envision that the core content will be revised on a periodic basis; so, too, will the curriculum require periodic updating. Kern et al. said it best: “For a successful curriculum, curricular development never really ends. Rather curriculum evolves, based on evaluation results, changes in resources, changes in targeted learners, and changes in the material requiring mastery.”34
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22. Miller GE. The assessment of clinical skills/competence/ performance. Acad Med. 1990;65(9): s63–7. 23. Felder RM, Brent R. Understanding student differences. J Engr Educ. 2005;94(1):57–72. 24. Felder RM, Soloman BA. Index of learning styles. www4.ncsu. edu/unity/lockers/users/f/felder/public/ILSpage.html. Accessed June 23, 2013. 25. Soloman BA, Felder RM. Index of learning styles questionnaire. www.engr.ncsu.edu/learningstyles/ilsweb.html. Accessed June 23, 2013. 26. Hughes MT. Implementation. In: Kern DE, Thomas PA, Hughes MT, eds. Curriculum Development for Medical Education, 2nd ed. Baltimore: The Johns Hopkins University Press; 2009. 27. Norcini JJ, Holmboe ES, Hawkins RE. Evaluation challenges in the era of outcomes-based education. In: Holmboe ES, Hawkins RE, eds. Practical Guide to the Evaluation of Clinical Competence. Philadelphia, PA: Mosby; 2008. 28. Cooke M, Irby DM, O’Brien BC. Educating Physicians: A Call for Reform of Medical School and Residency. Stanford, CA: Josey-Bass Higher and Adult Education Series; 2010. 29. Dreyfus HL. On the Internet. Thinking in Action Series. New York: Routledge; 2001. 30. Dreyfus H, Dreyfus S. Mind over Medicine. New York: Free Press; 1982. 31. Holmboe ES. Practice audit, medical record review, and chartstimulated recall. In: Holmboe ES, Hawkins RE, eds. Practical Guide to the Evaluation of Clinical Competence. Philadelphia, PA: Mosby; 2008. 32. Lockyer JM, Clyman SG. Multisource feedback (360-degree evaluation). In: Holmboe ES, Hawkins RE, eds. Practical Guide to the Evaluation of Clinical Competence. Philadelphia, PA: Mosby; 2008. 33. Cone DC, O’Connor RE, Fowler RL, eds. Emergency Medical Services: Clinical Practice and Systems Oversight. Dubuque, IA: Kendall Hunt; 2009. 34. Kern DE. Overview: A six-step approach to curriculum development. In: Kern DE, Thomas PA, Hughes MT, eds. Curriculum Development for Medical Education, 2nd ed. Baltimore: The Johns Hopkins University Press; 2009 35. Ogrinc G, Headrick LA, Mutha S, Coleman MT, O’Donnell J, Miles PV. A framework for teaching medical students and residents about practice-based learning and improvement, synthesized from a literature review. Acad Med. 2003;78:748– 56.
SUPPLEMENTAL MATERIAL AVAILABLE ONLINE Appendix 1: Suggested Curriculum of EMS Medicine. Appendix 2: A 12-month Model Curriculum.
