BRIEF REPORT
State of Undergraduate Education in Emergency Medicine: A National Survey of Clerkship Directors Sorabh Khandelwal, MD, David P. Way, MEd, David A. Wald, DO, Jonathan Fisher, MD, MPH, Douglas S. Ander, MD, Lorraine Thibodeau, MD, and David E. Manthey, MD
Abstract Background: The discipline of emergency medicine (EM) has rapidly changed over the past 10 years, resulting in greater involvement of the specialty in undergraduate medical education. Objectives: The authors sought to present a review of how, when, and where EM is currently taught in U.S. medical schools and to include general program characteristics, such as number of required clerkships, clinical expectations and experiences, use of the national curriculum guide, didactic content, and methods of assessment and grading. Methods: The authors surveyed representatives of the 128 U.S. allopathic medical schools on medical education in 2010. Contacts were drawn from established databases, direct inquiries, and medical school websites. Up to five attempts were made to contact representatives through e-mail and telephone. Descriptive statistics were used to summarize the data. Results: The survey response rate was 83.6%. Fifty-two percent of medical schools now require students to complete EM clerkships. Required EM clerkships usually last 4 weeks and take place during the fourth year of medical school. They require students to complete a mean (SD) of 14.3 (2.8) shifts, which average 8.9 (1.4) hours in length. Programs include a mean (SD) of 18 (10.4) hours of didactics. Approximately 60% of respondents report that both residents and attending physicians precept students. Assessments of students primarily include written clinical performance assessments and end-of-rotation written tests. These assessments contribute 66.8 and 24.5%, respectively, to the clerkship grade. Conclusions: Currently more than half of all U.S. medical schools require EM clerkships in their undergraduate medical curricula. This article reports an overview of EM programs at the undergraduate level. ACADEMIC EMERGENCY MEDICINE 2014; 21:92–95 © 2013 by the Society for Academic Emergency Medicine
T
hroughout the past decade, emergency medicine (EM) has become increasingly involved in undergraduate medical school curricula. To better define the expectations of EM education at this level, Manthey et al.1 published an EM curriculum guide in 2006. Additionally, the Clerkship Directors in
Emergency Medicine (CDEM) was formed in 2007 to guide and support EM educators in their efforts to develop and administer EM education to medical students. In 2007, the first study of U.S. EM curricula was published, providing a comprehensive report on general EM program characteristics.2 The purpose of this study
From the Department of Emergency Medicine, The Ohio State University (SK), Columbus, OH; the Department of Emergency Medicine, Temple University (DAW), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (JF), Boston, MA; the Department of Emergency Medicine, Emory University (DSA), Atlanta, GA; the Department of Emergency Medicine, Albany Medical Center (LT), Albany, NY; the Department of Emergency Medicine, Wake Forest University (DEM), Winston-Salem, NC; and the Department of Emergency Medicine, Office of Evaluation, Curriculum Research and Development (DPW), The Ohio State University, Columbus, OH. Received May 23, 2013; revision received July 22, 2013; accepted July 26, 2013. Presented at the Society for Academic Emergency Medicine Annual Meeting, Atlanta, GA, May 2013. The authors have no financial or personal conflicts to report in the creation of this work. The manuscript is submitted on behalf of the Clerkship Directors in Emergency Medicine (CDEM). The authors have no relevant financial information or potential conflicts of interest to disclose. Supervising Editor: John Burton, MD. Address for correspondence and reprints: Sorabh Khandelwal, MD; e-mail: [email protected].
92
ISSN 1069-6563 PII ISSN 1069-6563583
© 2013 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12290
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ACADEMIC EMERGENCY MEDICINE • January 2014, Vol. 21, No. 1 • www.aemj.org
was to update the state of EM education at U.S. medical Table 1 schools. Frequency and Percentage (in Parentheses) of Responses to Four Questions*
METHODS
n (%)
Question
Study Design and Population The study population was EM clerkship directors at accredited allopathic medical schools in the United States (including Puerto Rico) that had enrolled students at all levels as of 2010 (N = 128). Newly formed medical schools (those with preliminary or provisional status) were not included. The roster of the 128 medical schools was obtained from the Association of American Medical Colleges website. Contact information of clerkship directors was obtained from the Society for Academic Emergency Medicine (SAEM) membership database and individual school websites and through direct contact with school representatives. The study was reviewed and determined exempt research by the institutional review board at The Ohio State University School of Medicine. Consent was implied by survey completion. Survey Content and Administration We developed a survey guided by the literature and consideration for items published in similar studies. Before implementation, the survey was piloted with a small group of EM medical educators not affiliated with the study for the purpose of improving clarity, readability, and comprehensiveness. The final survey was reviewed by a survey development specialist. We distributed the survey (SurveyMonkey, Palo Alto, CA) in five waves throughout the academic year 2010–11. For schools without identifiable clerkship directors, the survey was sent to curriculum deans. Follow-ups were sent to nonrespondents monthly from September through November 2010. In April 2011, nonrespondents were contacted by telephone. Over 9 months, all targeted schools were contacted by e-mail or phone until a reply was received or five attempts had been made. Data Analysis We present descriptive outcomes using IBM- SPSS Statistics for Windows, version 19.0, 2010 release (IBM SPSS, Armonk, NY). RESULTS We received surveys from 106 respondents, who represented 107 of the 128 accredited U.S. medical schools (one respondent represented two institutions) for an 83.6% return rate. Required/Elective Experiences Table 1 illustrates the frequencies and percentages of EM courses, the level they are offered, and whether they are required, elective, or extracurricular experiences. Extracurricular activities are those activities offered by a department but not formally recognized for credit. Fifty-two percent of medical schools said that they require students to complete EM clerkships. The most common structure of the required EM clerkships is 4 weeks in length, offered during the fourth year of medical school.
1. Required EM clerkship? No Yes 2. Length of required EM clerkship? 2 weeks in length 4 weeks in length Other length 3. At what level is EM available? First year Second year Third year required Fourth year required Third year electives Fourth year electives Advanced EM elective (i.e., acting internship) 4. Content of EM electives and extracurricular experiences? Pediatric EM Ultrasound Research Toxicology EMS EMS land-based EMS air medical Advanced EMS track Wilderness medicine International EM Other electives or extracurricular experiences
51 (47.7) 56 (52.3) 10 (17.9) 44 (78.6) 2 (3.5) 25 22 15 42 30 71 41 Electives 40 37 36 28 22 — — 21 17 11 7
(37.4) (34.6) (33.6) (26.2) (20.6) (24.3) (15.9) (10.3) (6.5)
(23.4) (20.6) (14.0) (39.3) (28.0) (66.4) (38.3) Extracurricular 61 41 17 27 50 18 11 5 3 5
(57.0) (38.3) (15.9) (25.2) — (46.7) (16.8) (10.3) (4.7) (2.8) (4.7)
The percentages are based on the number of total respondents (N = 107) even though participants were permitted to check more than one response to questions 3 and 4. One school requires EM in both the third and the fourth years. *Four questions: “1. Do you have a required clerkship?” “2. What is the duration of your required clerkship?” “3. When is emergency medicine available to medical students?” and “4. What is the content of EM elective courses and adjunct experiences within clerkships?”
Didactic Curriculum Clerkship directors reported a mean of 18 (10.4) hours of lectures per clerkship. More than a third (40 of 107, 37%) of respondents base their lectures on the 2006 EM curriculum guide.1 Three-quarters of the respondents incorporate simulation (80 of 107, 75%). Ninety-four percent (75 of 80) of respondents report that simulation is primarily used to teach “diagnosis and management.” Other teaching subjects included procedures (61.3%, 49 of 80) and interdisciplinary team building (49 of 80, 61.3%). The mean (SD) number of hours spent on simulation is 5.0 (3.8) hours per rotation. CDEM developed the “Emergency Medicine Clerkship Primer” to be used as a nationally standardized rotation manual for medical students.3 Just over a third (40 of 107, 37.4%) report using the CDEM Primer, and 23% (9 of 40) require it. Forty-four percent (47 of 107) of programs report that they do not require a textbook. Among
94
Khandelwal et al. • STATE OF UNDERGRADUATE EM EDUCATION
those who do, the most commonly used are authored by Mahadevan and Garmel (14%),4 Hamilton (9.3%),5 and Cline (6.5%).6 On average, the percentage of fulltime EM faculty who deliver lectures is 31.6%. While 49% of programs (52 of 107) said that they involve residents in delivering lectures, only 23 of those 52 (44.2%) said that they provide training to residents on lecturing, and only 15 of 52 (28.8%) provide training in adult learning theory.
guide based on their own needs and available resources. We found that clerkship directors seem to be following the EM curriculum guide for recommended patient encounters and procedures. We also found that programs have not completely adopted the SAEM/CDEM examination for assessment of EM knowledge, despite the fact that it was developed based on the EM curriculum guide. A new EM examination, the National Board of Medical Examiners EM Advanced Clinical Examination, was introduced in 2013. It too is based on the EM curriculum guide. We anticipate that, as published norms for this test become available, clerkship directors will take a more direct interest in the EM curriculum guide. Our study also highlighted several important issues that warrant further investigation. First, while close to 90% of programs involve residents in teaching, only 45.5% train them to teach. Both the Accreditation Council for Graduate Medical Education and the Liaison Committee on Medical Education (LCME) call for improving undergraduate education through development of residents as teachers.7 Second, many clerkship directors believe that use of the electronic medical record for documentation is a skill that needs to be formally taught; however, our data suggest that students are limited in their ability to document in these systems. The challenge of integrating electronic records into undergraduate education is not unique to EM, but is also a challenge faced by other specialties.8 Third, given the evidence for the use of objective structured clinical examinations for performance assessment, it was surprising that only three programs report using them and that they only account for an average of 8.3% toward the composite grade.9 Finally, we found that direct observation occurred infrequently in EM clerkships. This finding is concerning because undergraduate education is moving toward a competency-based model, and direct observation of student performance is a powerful tool for the assessment of many of these competencies.10
Clinical Curriculum The number of clinical shifts averaged 14.3 (2.8) per rotation, the average shift length being 8.9 (1.4) hours. Most respondents (68 of 107, 63.6%) reported that both attending physicians and residents are involved with precepting students. Thirty percent (32 of 107) use only attendings, and 1.9% (2 of 107) used only residents. Most clerkship directors (77 of 107, 71.9%) require students to maintain patient encounter logs. More than two-thirds (74 of 107, 69.2%) have students log their clinical procedures. Forty-four percent (47 of 107) require students to see a list of patients with specific chief complaints. While the majority (82 of 107, 76.6%) of our respondents use an electronic medical record system, fewer than half (36 of 82, 43.9%) allow students to document in this system. Assessment and Grading Most programs use a clinical performance assessment form to establish the student’s grade in the course (101 of 107, 94.4%). This assessment, on average, accounts for 66.8% of the student’s final grade. A large percentage of respondents (86 of 107, 80.4%) report using endof-shift assessment forms. All programs expect faculty to complete the forms, while less than half require residents to complete assessment forms (48 of 107, 44.9%). The second most influential determinant of the grade is the written examination (61 of 107, 57.0%). On average, the written examination score contributes 24.5% to the grade. Less than half of programs that give written examinations (26 of 61, 42.6%) use the SAEM/CDEM Test. Other common assessments cited include case presentations (41 of 107, 38.3%) and conference attendance (38 of 107, 35.5%). Fifty-three percent (57 of 107) report using direct observation as an assessment tool. Fiftyfour percent (35 of 57) of those who said they use direct observation mandate it.
LIMITATIONS Because we focused our efforts on obtaining data from EM programs directly affiliated with academic health centers, our results may not generalize to community programs, programs with widely dispersed or regional affiliates, and the LCME-accredited institutions in Canada.
DISCUSSION
CONCLUSIONS
United States medical schools are increasingly requiring an EM experience. Fifty-two percent require EM clerkships, compared to 36% in the 2007 survey.2 While the publication of the EM curriculum guide and the development of CDEM were designed to promote a standardized undergraduate EM educational experience, we found that many institutions prefer to design their own teaching materials and assessments. Only 37% of clerkship directors report basing their curriculum on the 2006 EM curriculum guide. We do not believe that this finding implies that the content is not being covered, but rather that clerkship directors enhance or modify their programs beyond the recommendations of the curriculum
Currently more than half of all U.S. allopathic medical schools require EM clerkships during medical school. Many institutions that do not require EM still offer EM education. While the publication of the EM curriculum guide and the work of CDEM have attempted to standardize EM education at the undergraduate level, there does not seem to be universal adoption. Several challenges persist, as EM becomes an ever-increasing content presence in the undergraduate medical curriculum in the United States.
ACADEMIC EMERGENCY MEDICINE • January 2014, Vol. 21, No. 1 • www.aemj.org The authors thank Dr. Robert Rogers, Associate Professor of Emergency Medicine at the University of Maryland, for his help in designing the survey instrument.
References 1. Manthey DE, Coates WC, Ander DS, et al. Report of the Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide. Ann Emerg Med. 2006;47:e1–7. 2. Wald DA, Manthey DE, Kruus L, Tripp M, Barrett J, Amoroso B. The state of the clerkship: a survey of emergency medicine clerkship directors. Acad Emerg Med. 2007;14:629–34. 3. Wald DA. Emergency Medicine Clerkship Primer: “A Manual for Medical Students.” CDEM Publication 2011. Available at: https://urldefense.proofpoint.com/v1/url?u=http://www.cdemcurriculum.org/ index.php/welcome/downloads&k=ux7ohqYFcw1oDo 0gOpSLlw%3D%3D%0A&r=1y%2BocaPYkmeGz%2Fp OGGanjnI%2BcD4kZn2fKnp348B1wU8%3D%0A&m= K%2BudfklYTQ9rGS8PjFeNzSaQGuNJlxmC0ZuYg% 2F2%2BktM%3D%0A&s=c0fc0158c36db85e25e7b41 95b0ff0a623100d21fd711f2ab0002b2fcea53fc7. Accessed Dec 9, 2013.
95
4. Mahadevan SV, Garmel GM, eds. An Introduction to Clinical Emergency Medicine. New York, NY: Cambridge University Press, 2012. 5. Hamilton GC, Sanders AB, Strange G, Trott AT. Emergency Medicine: An Approach to Clinical Problem-Solving. Philadelphia PA: Saunders Elsevier, 2002. 6. Cline D, Ma OJ, Cydulka R, Meckler G, Thomas S, Handel D. Tintinalli’s Emergency Medicine Manual. New York, NY: McGraw-Hill Companies, 2012. 7. Bensinger LD, Meah YS, Smith LG. Resident as teacher: the Mount Sinai experience and a review of the literature. Mt Sinai J Med. 2005;72:307–11. 8. Mintz M, Narvarte HJ, O’Brien KE, Papp KK, Thomas M, Durning SJ. Use of electronic medical records by physicians and students in academic internal medicine settings. Acad Med. 2009;84:1698–704. 9. Patricio MF, Juliao M, Fareleira F, Carneiro AV. Is the OSCE a feasible tool to assess competencies in undergraduate medical education? Med Teach. 2013;35:503–14. 10. Carraccio CL, Englander R. From Flexner to competencies: reflections on a decade and the journey ahead. Acad Med. 2013;88:1067–73.
State of Undergraduate Education in Emergency Medicine: A National Survey of Clerkship Directors Sorabh Khandelwal, MD, David P. Way, MEd, David A. Wald, DO, Jonathan Fisher, MD, MPH, Douglas S. Ander, MD, Lorraine Thibodeau, MD, and David E. Manthey, MD
Abstract Background: The discipline of emergency medicine (EM) has rapidly changed over the past 10 years, resulting in greater involvement of the specialty in undergraduate medical education. Objectives: The authors sought to present a review of how, when, and where EM is currently taught in U.S. medical schools and to include general program characteristics, such as number of required clerkships, clinical expectations and experiences, use of the national curriculum guide, didactic content, and methods of assessment and grading. Methods: The authors surveyed representatives of the 128 U.S. allopathic medical schools on medical education in 2010. Contacts were drawn from established databases, direct inquiries, and medical school websites. Up to five attempts were made to contact representatives through e-mail and telephone. Descriptive statistics were used to summarize the data. Results: The survey response rate was 83.6%. Fifty-two percent of medical schools now require students to complete EM clerkships. Required EM clerkships usually last 4 weeks and take place during the fourth year of medical school. They require students to complete a mean (SD) of 14.3 (2.8) shifts, which average 8.9 (1.4) hours in length. Programs include a mean (SD) of 18 (10.4) hours of didactics. Approximately 60% of respondents report that both residents and attending physicians precept students. Assessments of students primarily include written clinical performance assessments and end-of-rotation written tests. These assessments contribute 66.8 and 24.5%, respectively, to the clerkship grade. Conclusions: Currently more than half of all U.S. medical schools require EM clerkships in their undergraduate medical curricula. This article reports an overview of EM programs at the undergraduate level. ACADEMIC EMERGENCY MEDICINE 2014; 21:92–95 © 2013 by the Society for Academic Emergency Medicine
T
hroughout the past decade, emergency medicine (EM) has become increasingly involved in undergraduate medical school curricula. To better define the expectations of EM education at this level, Manthey et al.1 published an EM curriculum guide in 2006. Additionally, the Clerkship Directors in
Emergency Medicine (CDEM) was formed in 2007 to guide and support EM educators in their efforts to develop and administer EM education to medical students. In 2007, the first study of U.S. EM curricula was published, providing a comprehensive report on general EM program characteristics.2 The purpose of this study
From the Department of Emergency Medicine, The Ohio State University (SK), Columbus, OH; the Department of Emergency Medicine, Temple University (DAW), Philadelphia, PA; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center (JF), Boston, MA; the Department of Emergency Medicine, Emory University (DSA), Atlanta, GA; the Department of Emergency Medicine, Albany Medical Center (LT), Albany, NY; the Department of Emergency Medicine, Wake Forest University (DEM), Winston-Salem, NC; and the Department of Emergency Medicine, Office of Evaluation, Curriculum Research and Development (DPW), The Ohio State University, Columbus, OH. Received May 23, 2013; revision received July 22, 2013; accepted July 26, 2013. Presented at the Society for Academic Emergency Medicine Annual Meeting, Atlanta, GA, May 2013. The authors have no financial or personal conflicts to report in the creation of this work. The manuscript is submitted on behalf of the Clerkship Directors in Emergency Medicine (CDEM). The authors have no relevant financial information or potential conflicts of interest to disclose. Supervising Editor: John Burton, MD. Address for correspondence and reprints: Sorabh Khandelwal, MD; e-mail: [email protected].
92
ISSN 1069-6563 PII ISSN 1069-6563583
© 2013 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12290
93
ACADEMIC EMERGENCY MEDICINE • January 2014, Vol. 21, No. 1 • www.aemj.org
was to update the state of EM education at U.S. medical Table 1 schools. Frequency and Percentage (in Parentheses) of Responses to Four Questions*
METHODS
n (%)
Question
Study Design and Population The study population was EM clerkship directors at accredited allopathic medical schools in the United States (including Puerto Rico) that had enrolled students at all levels as of 2010 (N = 128). Newly formed medical schools (those with preliminary or provisional status) were not included. The roster of the 128 medical schools was obtained from the Association of American Medical Colleges website. Contact information of clerkship directors was obtained from the Society for Academic Emergency Medicine (SAEM) membership database and individual school websites and through direct contact with school representatives. The study was reviewed and determined exempt research by the institutional review board at The Ohio State University School of Medicine. Consent was implied by survey completion. Survey Content and Administration We developed a survey guided by the literature and consideration for items published in similar studies. Before implementation, the survey was piloted with a small group of EM medical educators not affiliated with the study for the purpose of improving clarity, readability, and comprehensiveness. The final survey was reviewed by a survey development specialist. We distributed the survey (SurveyMonkey, Palo Alto, CA) in five waves throughout the academic year 2010–11. For schools without identifiable clerkship directors, the survey was sent to curriculum deans. Follow-ups were sent to nonrespondents monthly from September through November 2010. In April 2011, nonrespondents were contacted by telephone. Over 9 months, all targeted schools were contacted by e-mail or phone until a reply was received or five attempts had been made. Data Analysis We present descriptive outcomes using IBM- SPSS Statistics for Windows, version 19.0, 2010 release (IBM SPSS, Armonk, NY). RESULTS We received surveys from 106 respondents, who represented 107 of the 128 accredited U.S. medical schools (one respondent represented two institutions) for an 83.6% return rate. Required/Elective Experiences Table 1 illustrates the frequencies and percentages of EM courses, the level they are offered, and whether they are required, elective, or extracurricular experiences. Extracurricular activities are those activities offered by a department but not formally recognized for credit. Fifty-two percent of medical schools said that they require students to complete EM clerkships. The most common structure of the required EM clerkships is 4 weeks in length, offered during the fourth year of medical school.
1. Required EM clerkship? No Yes 2. Length of required EM clerkship? 2 weeks in length 4 weeks in length Other length 3. At what level is EM available? First year Second year Third year required Fourth year required Third year electives Fourth year electives Advanced EM elective (i.e., acting internship) 4. Content of EM electives and extracurricular experiences? Pediatric EM Ultrasound Research Toxicology EMS EMS land-based EMS air medical Advanced EMS track Wilderness medicine International EM Other electives or extracurricular experiences
51 (47.7) 56 (52.3) 10 (17.9) 44 (78.6) 2 (3.5) 25 22 15 42 30 71 41 Electives 40 37 36 28 22 — — 21 17 11 7
(37.4) (34.6) (33.6) (26.2) (20.6) (24.3) (15.9) (10.3) (6.5)
(23.4) (20.6) (14.0) (39.3) (28.0) (66.4) (38.3) Extracurricular 61 41 17 27 50 18 11 5 3 5
(57.0) (38.3) (15.9) (25.2) — (46.7) (16.8) (10.3) (4.7) (2.8) (4.7)
The percentages are based on the number of total respondents (N = 107) even though participants were permitted to check more than one response to questions 3 and 4. One school requires EM in both the third and the fourth years. *Four questions: “1. Do you have a required clerkship?” “2. What is the duration of your required clerkship?” “3. When is emergency medicine available to medical students?” and “4. What is the content of EM elective courses and adjunct experiences within clerkships?”
Didactic Curriculum Clerkship directors reported a mean of 18 (10.4) hours of lectures per clerkship. More than a third (40 of 107, 37%) of respondents base their lectures on the 2006 EM curriculum guide.1 Three-quarters of the respondents incorporate simulation (80 of 107, 75%). Ninety-four percent (75 of 80) of respondents report that simulation is primarily used to teach “diagnosis and management.” Other teaching subjects included procedures (61.3%, 49 of 80) and interdisciplinary team building (49 of 80, 61.3%). The mean (SD) number of hours spent on simulation is 5.0 (3.8) hours per rotation. CDEM developed the “Emergency Medicine Clerkship Primer” to be used as a nationally standardized rotation manual for medical students.3 Just over a third (40 of 107, 37.4%) report using the CDEM Primer, and 23% (9 of 40) require it. Forty-four percent (47 of 107) of programs report that they do not require a textbook. Among
94
Khandelwal et al. • STATE OF UNDERGRADUATE EM EDUCATION
those who do, the most commonly used are authored by Mahadevan and Garmel (14%),4 Hamilton (9.3%),5 and Cline (6.5%).6 On average, the percentage of fulltime EM faculty who deliver lectures is 31.6%. While 49% of programs (52 of 107) said that they involve residents in delivering lectures, only 23 of those 52 (44.2%) said that they provide training to residents on lecturing, and only 15 of 52 (28.8%) provide training in adult learning theory.
guide based on their own needs and available resources. We found that clerkship directors seem to be following the EM curriculum guide for recommended patient encounters and procedures. We also found that programs have not completely adopted the SAEM/CDEM examination for assessment of EM knowledge, despite the fact that it was developed based on the EM curriculum guide. A new EM examination, the National Board of Medical Examiners EM Advanced Clinical Examination, was introduced in 2013. It too is based on the EM curriculum guide. We anticipate that, as published norms for this test become available, clerkship directors will take a more direct interest in the EM curriculum guide. Our study also highlighted several important issues that warrant further investigation. First, while close to 90% of programs involve residents in teaching, only 45.5% train them to teach. Both the Accreditation Council for Graduate Medical Education and the Liaison Committee on Medical Education (LCME) call for improving undergraduate education through development of residents as teachers.7 Second, many clerkship directors believe that use of the electronic medical record for documentation is a skill that needs to be formally taught; however, our data suggest that students are limited in their ability to document in these systems. The challenge of integrating electronic records into undergraduate education is not unique to EM, but is also a challenge faced by other specialties.8 Third, given the evidence for the use of objective structured clinical examinations for performance assessment, it was surprising that only three programs report using them and that they only account for an average of 8.3% toward the composite grade.9 Finally, we found that direct observation occurred infrequently in EM clerkships. This finding is concerning because undergraduate education is moving toward a competency-based model, and direct observation of student performance is a powerful tool for the assessment of many of these competencies.10
Clinical Curriculum The number of clinical shifts averaged 14.3 (2.8) per rotation, the average shift length being 8.9 (1.4) hours. Most respondents (68 of 107, 63.6%) reported that both attending physicians and residents are involved with precepting students. Thirty percent (32 of 107) use only attendings, and 1.9% (2 of 107) used only residents. Most clerkship directors (77 of 107, 71.9%) require students to maintain patient encounter logs. More than two-thirds (74 of 107, 69.2%) have students log their clinical procedures. Forty-four percent (47 of 107) require students to see a list of patients with specific chief complaints. While the majority (82 of 107, 76.6%) of our respondents use an electronic medical record system, fewer than half (36 of 82, 43.9%) allow students to document in this system. Assessment and Grading Most programs use a clinical performance assessment form to establish the student’s grade in the course (101 of 107, 94.4%). This assessment, on average, accounts for 66.8% of the student’s final grade. A large percentage of respondents (86 of 107, 80.4%) report using endof-shift assessment forms. All programs expect faculty to complete the forms, while less than half require residents to complete assessment forms (48 of 107, 44.9%). The second most influential determinant of the grade is the written examination (61 of 107, 57.0%). On average, the written examination score contributes 24.5% to the grade. Less than half of programs that give written examinations (26 of 61, 42.6%) use the SAEM/CDEM Test. Other common assessments cited include case presentations (41 of 107, 38.3%) and conference attendance (38 of 107, 35.5%). Fifty-three percent (57 of 107) report using direct observation as an assessment tool. Fiftyfour percent (35 of 57) of those who said they use direct observation mandate it.
LIMITATIONS Because we focused our efforts on obtaining data from EM programs directly affiliated with academic health centers, our results may not generalize to community programs, programs with widely dispersed or regional affiliates, and the LCME-accredited institutions in Canada.
DISCUSSION
CONCLUSIONS
United States medical schools are increasingly requiring an EM experience. Fifty-two percent require EM clerkships, compared to 36% in the 2007 survey.2 While the publication of the EM curriculum guide and the development of CDEM were designed to promote a standardized undergraduate EM educational experience, we found that many institutions prefer to design their own teaching materials and assessments. Only 37% of clerkship directors report basing their curriculum on the 2006 EM curriculum guide. We do not believe that this finding implies that the content is not being covered, but rather that clerkship directors enhance or modify their programs beyond the recommendations of the curriculum
Currently more than half of all U.S. allopathic medical schools require EM clerkships during medical school. Many institutions that do not require EM still offer EM education. While the publication of the EM curriculum guide and the work of CDEM have attempted to standardize EM education at the undergraduate level, there does not seem to be universal adoption. Several challenges persist, as EM becomes an ever-increasing content presence in the undergraduate medical curriculum in the United States.
ACADEMIC EMERGENCY MEDICINE • January 2014, Vol. 21, No. 1 • www.aemj.org The authors thank Dr. Robert Rogers, Associate Professor of Emergency Medicine at the University of Maryland, for his help in designing the survey instrument.
References 1. Manthey DE, Coates WC, Ander DS, et al. Report of the Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide. Ann Emerg Med. 2006;47:e1–7. 2. Wald DA, Manthey DE, Kruus L, Tripp M, Barrett J, Amoroso B. The state of the clerkship: a survey of emergency medicine clerkship directors. Acad Emerg Med. 2007;14:629–34. 3. Wald DA. Emergency Medicine Clerkship Primer: “A Manual for Medical Students.” CDEM Publication 2011. Available at: https://urldefense.proofpoint.com/v1/url?u=http://www.cdemcurriculum.org/ index.php/welcome/downloads&k=ux7ohqYFcw1oDo 0gOpSLlw%3D%3D%0A&r=1y%2BocaPYkmeGz%2Fp OGGanjnI%2BcD4kZn2fKnp348B1wU8%3D%0A&m= K%2BudfklYTQ9rGS8PjFeNzSaQGuNJlxmC0ZuYg% 2F2%2BktM%3D%0A&s=c0fc0158c36db85e25e7b41 95b0ff0a623100d21fd711f2ab0002b2fcea53fc7. Accessed Dec 9, 2013.
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4. Mahadevan SV, Garmel GM, eds. An Introduction to Clinical Emergency Medicine. New York, NY: Cambridge University Press, 2012. 5. Hamilton GC, Sanders AB, Strange G, Trott AT. Emergency Medicine: An Approach to Clinical Problem-Solving. Philadelphia PA: Saunders Elsevier, 2002. 6. Cline D, Ma OJ, Cydulka R, Meckler G, Thomas S, Handel D. Tintinalli’s Emergency Medicine Manual. New York, NY: McGraw-Hill Companies, 2012. 7. Bensinger LD, Meah YS, Smith LG. Resident as teacher: the Mount Sinai experience and a review of the literature. Mt Sinai J Med. 2005;72:307–11. 8. Mintz M, Narvarte HJ, O’Brien KE, Papp KK, Thomas M, Durning SJ. Use of electronic medical records by physicians and students in academic internal medicine settings. Acad Med. 2009;84:1698–704. 9. Patricio MF, Juliao M, Fareleira F, Carneiro AV. Is the OSCE a feasible tool to assess competencies in undergraduate medical education? Med Teach. 2013;35:503–14. 10. Carraccio CL, Englander R. From Flexner to competencies: reflections on a decade and the journey ahead. Acad Med. 2013;88:1067–73.
