Teaching Emergency Medicine for Medical Students Jim Holliman

Teaching Emergency Medicine for Medical Students Jim Holliman, M. D. , F. A. C. E. P. Professor of Military and Emergency Medicine Uniformed Services University Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, U. S. A.

Benefits of Training All Medical Students in Emergency Medicine (E. M. ) §Ensures exposure to proper emergency management of common conditions. §Meets public expectation that all doctors should know basic emergency care. §Encourages some of students to pursue E. M. residency training. §Allows students to appreciate the knowledge, areas of expertise, & skills of the E. M. physicians. §Some may develop interest in pursuing E. M. research projects and working with the E. M. faculty.

Excellent Background Reference on Medical Student Education in E. M. • Medical Student Educator’s Handbook – Available on the Clerkship Directors of E. M. Academy sub-web page (on the S. A. E. M. web page www. saem. org). – Covers all aspects of E. M. medical student education. – Extensive additional information is also on the S. A. E. M. web site.

E. M. Training for Students Leads to Better Interns • Allows ability & confidence in managing basic emergencies. • Familiarizes them with Emergency Department (E. D. ) operations and needs. • Improves working relationship with E. M. faculty & Interns / residents. • Allows them to learn cost-effective use of ancillary tests.

E. M. Curriculum in Medical School Vertical Integration • Basic Science Courses • Pre-Clinical Courses • Clinical Rotations • Electives in Emergency Medicine E. M. faculty should participate in all 4 “levels”

General Structure to Consider for E. M. Training for 1 st & 2 nd Year Medical Students §E. M. faculty involvement with lectures on basic & applied physiology (E. M. faculty are particularly good at case presentations for case-based learning). §Extracurricular lectures on clinical topics. §Extracurricular "workshops" or "labs" : –Suture technique –Airway management –Blood drawing –Intravenous line placement –Splint & cast application –EKG interpretation –X-ray interpretation Having E. M. faculty advise an E. M. Student “Club” or Interest Group is one way to do this

General Structure to Consider for E. M. Training for 3 rd & 4 th Year Medical Students § 3 rd year options : –Observational elective in E. D. ( 2 to 4 weeks) –Elective in prehospital (ambulance) care § 4 th year options : – 1 month elective ( or required) in E. D. – 1 month elective in Toxicology – 1 month elective in prehospital care –Students interested in a career in E. M. (applying to E. M. residency) should have 2 months of E. D. electives early in their final year

Unique Subjects to Teach Students and Residents in the Emergency Department (E. D. ) Cost-effective ancillary test ordering Efficiency in patient flow Managing multiple simultaneous patients Coordinating prehospital and E. D. care Focused approach to medical problems Speed & efficiency of evaluations Efficient use of ancillary personnel Efficient recording & transmittal of data Injury & violence prevention

Minimum Basic Subjects to Teach Medical Students & Residents in the E. D. §Recognition of emergencies §Airway management §Cardiopulmonary Resuscitation (CPR) §Focused evaluation of : –Headache –Chest pain –Dyspnea –Abdominal pain –Fever §Suturing / wound care

The E. M. Rotation Core Curriculum Should Be Clearly Defined for the Students ƒ Methods to verify completion or "passing" should be clear to students. ƒ Should cover the most important and / or most frequent clinical problems (should not try to cover everything). ƒ Amount and breadth of core curriculum depend on length of training period.

Additional Core Curriculum Topics To Consider for Medical Students & Non-EM Residents ƒ Dysrhythmias ƒ Ophthalmic emergencies ƒ E. N. T. emergencies ƒ Dental emergencies ƒ Endocrine emergencies ƒ Oncologic emergencies ƒ Hematologic emergencies ƒ Allergic emergencies ƒ Dermatologic emergencies ƒ Environmental emergencies ƒ Gynecologic emergencies ƒ Obstetric emergencies ƒ Toxicologic emergencies ƒ Urologic emergencies ƒ Neurologic emergencies ƒ Psychiatric emergencies ƒ Injury and violence prevention ƒ Prehospital care ƒ Trauma (major, & bodyregion specific)

Basic General Topics Which Might Need to be Covered or Reinforced in the E. D. ƒ Basic EKG interpretation ƒ Antibiotic selection ƒ Radiograph interpretation ƒ Sterile technique ƒ Universal precautions ƒ Neurologic exam ƒ Eye or E. N. T. exams ƒ Spine immobilization / splinting ƒ Blood drawing and IV line insertion ƒ Death notification

List of Procedural Skills to Consider that Rotating Medical Students or Non-EM Residents Should Attain ƒ Basic airway maneuvers ƒ Peripheral IV line insertion ƒ Nasogastric tube insertion ƒ Foley catheterization ƒ Local anesthesia ƒ Wound suturing ƒ Splinting (+/- casting) ƒ Lumbar puncture ƒ +/- arterial puncture for blood gases

Suggested Principles for Designing a Teaching Curriculum for Students & Residents in the E. D. ƒ Cover all important core topics didactically –Lectures and / or assigned readings ƒ Monitor completion of core topics –"Sign-off" sheets –Sessions with course director –Written test at end of rotation ƒ Have trainee's time "protected" from clinical duties for core conferences or directed study

E. M. Clinical Rotation Features and Options Clinical teaching – Bedside physical diagnosis – Review of X-rays, EKG’s, ultrasounds Didactic teaching – Daily or “beginning of shift” “morning report” – Dedicated student lectures (can be delivered by residents) – Attendance at E. M. weekly residency lectures and Grand Rounds

The "Emergent Focus" of Emergency Medicine Teaching ƒ Teach students to FIRST assess for life threatening aspects : –Patient ƒ First : Airway / Breathing / Circulation ƒ "Treatment takes precedence over diagnosis" –EKG ƒ First look at ST segments & T waves –Radiographs ƒ First look for tube positions (ETT, etc. )

Suggested Bedside E. M. Teaching Techniques ƒ Require any student or junior resident to complete their History and Physical (H&P) exam in < 10 to 15 minutes, and then report to you, OR directly observe them conducting the H&P. ƒ Have trainee recite each step of their H&P to assess for completeness. ƒ Ask for trainee's opinion on Diagnosis or workup before stating your interpretation and plan. ƒ Allow "graded responsibility" as the trainee gains more experience and competence. ƒ Don't ask irrelevant or unimportant questions.

More Suggested Bedside E. M. Teaching Techniques ƒ Ask trainee to state the 3 most dangerous or 3 most likely diagnoses (rather than a complete differential diagnosis list). ƒ Ask trainee to justify reason for any lab test or radiograph ordered. ƒ Decide on options for plan of care based on anticipated results of tests ordered. –"Have a clear plan“ for each lab outcome possibility. ƒ Provide positive feedback as much as possible (see later slides for more on this).

More Suggested Bedside E. M. Teaching Techniques ƒ Even if very busy, take time to make at least one teaching point per case. ƒ Always review any differences in your H&P findings compared to the trainee's. ƒ Have trainees repeat their full report to you before they call a consultant (to make sure they understand the case). ƒ Back up your teaching points with medical literature citations as much as possible.

And More Suggested Bedside E. M. Teaching Techniques ƒ Take time & effort to show trainees and nurses cases with unusual findings. ƒ For efficiency, don't have trainees watch as you repeat an exam (unless they need direct observation of your technique). ƒ Don't point out exam or diagnosis errors by the trainee in front of the patient. ƒ Don't ever compromise patient care just to make a teaching point.

Other Clinical Teaching Techniques to Consider ƒ Review all EKG's done in the dept. with students when not busy. ƒ Review prior radiographs when not busy. ƒ Review trainees' written or computer reports for completeness & accuracy. –Timely feedback is important. ƒ Pull prior charts & ask trainees to make a diagnosis and treatment plan based on their review of these cases. ƒ Assign extra readings or reports to trainees demonstrating knowledge deficiency.

A. C. E. P. ’s E. M. Clinical Rotation Goals Guidelines – At the completion of the rotation, the student should be able to : • Perform an appropriately directed history and physical examination on emergency department patients. • Recognize emergent and urgent problems. • Develop a differential diagnosis for common presenting complaints such as chest pain, shortness of breath, and / or abdominal pain.

A. C. E. P. ’s E. M. Clinical Rotation Goals Guidelines (cont. ) * Develop an appropriate and cost-effective management plan for the emergency department patient presenting with common complaints such as acute asthma exacerbation, congestive heart failure, bronchitis, etc. * Demonstrate proper wound care and suture technique for simple lacerations. * Recognize ischemic patterns and dysrhythmias on EKG tracings.

A. C. E. P. ’s E. M. Clinical Rotation Goals Guidelines (cont. ) * Appropriately interpret results of complete blood count, chemistries, urinalysis, arterial blood gases, and other common laboratory studies. * Appropriately interpret radiographs of the chest, abdomen, and extremities. * Recognize the indications for specialty or subspecialty consultation.

Feedback for Medical Students : An Important Aspect of Their Rotation • In the setting of clinical medical education, feedback refers to “information describing students’ or house officers’ performance in a given activity that is intended to guide their future performance in that same or in a related activity”. JAMA 1983; 250: 777 -81.

Feedback Goals : • Praise the learner for a job well done or demonstration of a high level of knowledge • • Identify areas of weakness Provide direction or suggestions on how the learner can improve

Feedback and Evaluation • Feedback – Formative • • Provides an honest assessment of performance, including suggestions for improvement. Evaluation (done after Feedback) – Summative • Describes performance as it relates to the achievement of learning objectives.

The Six General Competencies the American Board of Medical Specialties Has Tasked All Specialties to Evaluate ƒ Patient care ƒ Medical knowledge ƒ Practice-based learning & improvement ƒ Interpersonal & communication skills ƒ Professionalism ƒ Systems-based practice So the Evaluation(s) of medical students’ clinical performance should be linked to these 6 items

Sample EM Clerkship Clinical Evaluation Card Student Name : Date : Evaluator : Block : Clinical Skills : (Learning Objectives) 1. Perform complaint -directed history & physical examinations 2. Develop case specific differential diagnosis 3. Present cases in a concise and organized fashion 4. Appropriate utilization and interpretation of diagnostic studies 5. Appropriate implementation of patient management plans 6. Demonstrate medical professionalism 7. Demonstrate an adequate fund of medical knowledge 8. Demonstrate proficiency in basic procedures Overall grade for the shift: Patient encounters: 1 – 2 H HP 3 – 5 P C F 6 or more

Feedback on clinical performance : Nonjudgmental, descriptive (refer to specific cases, performances, behaviors, or actions), objective appraisal of performance Positive feedback (What did the student do correct ? ) : Suggestions to improve clinical performance : Any additional comments : Discussed with student YES NO (second page of sample student evaluation form)

Suggested Criteria for HONORS Grade Evaluation for Students • • • A performance that is clearly superior. Reflects a comprehensive achievement of knowledge, skills, attitude, and behavior. The outstanding student. Consistently performs above expectations. Goes “above and beyond”.

Suggested Criteria for HIGH PASS Grade Evaluation for Students • • • A performance that is well beyond minimum course requirements. The “solid” medical student. Would be a good candidate for Emergency Medicine residency.

Suggested Criteria for a PASS Grade Evaluation for Students • • • A performance that meets basic course requirements. Reserved for the good student. The default grade.

Suggested Criteria for CONDITIONAL or FAIL Grade Evaluations for Students • • • A performance that falls well below expected minimum standards. Non-completion of pre-stated course requirements. Requires specific and detailed documentation by grading senior E. M. resident(s) and / or attending(s).

Suggested Expected Grade Distribution for Students • HONORS – • HIGH PASS – • • Usually reserved for the next 25 % to 35 %. PASS – • Usually reserved for the top 10 % of students. Usually reserved for the next 50 % to 60 %. Rigid cut off values are not used. Year to year the percentage of students receiving a particular grade may vary.

Options to Consider for E. M. Rotation Evaluations by Medical Students Ÿ Use same evaluation forms as residents fill out. Ÿ ? different forms for students applying to E. M. residencies Ÿ Mid-rotation interim eval. vs. end of rotation only Ÿ Exit interview Ÿ ? separate eval. form for this Ÿ ? with E. M. faculty vs. clerkship director Ÿ ? with person outside the E. M. dept. who provides later anonymous feedback report Ÿ End of year party

Options for Timing of Student Evaluations of E. M. Rotations and Faculty Ÿ Turn-in of evaluation form required : Ÿ Last day of rotation Ÿ Or after rotation but before grade issued Ÿ Or after rotation, & after grade issued Ÿ Or at end of academic year Ÿ Need to assure anonymity whatever submission timing is chosen

Structural Components of E. M. Rotations Which Students Should Separately Evaluate Ÿ E. M. faculty teaching Ÿ E. M. faculty clinical care Ÿ E. M. residents Ÿ Didactics / teaching materials Ÿ Clinical caseload Ÿ Goals / expectations

Options for Clinical Case Reporting by Students Which Can Affect Evaluations Ÿ Present cases to : Ÿ Next available (any) E. M. attending Ÿ Predesignated "student teacher" faculty Ÿ Predesignated senior E. M. "teaching resident" ƒ May limit E. M. faculty's ability to rate students for recommendation letters Ÿ ? alter for students applying to E. M. residencies versus those applying to other residencies

Analysis of the Student Rotation Evaluations Ÿ Most intense and complete review by clerkship director. Ÿ Independent review by E. M. residency director & Dept. director. Ÿ Summary evaluation report for rest of E. M. faculty once or more per year. Ÿ E. M. faculty should access comparative evaluations of other medical school rotations. Ÿ Need to have E. M. represented on school curriculum committee. Ÿ Correlate evaluations for E. M. -bound vs. non-E. M. -bound students. Ÿ May also need to separate evaluations for rotating students from other schools.

Options for Evaluations of E. M. Faculty by Students Ÿ Separate form for each faculty member : Ÿ Specify how much time, number of cases, or how many shifts student worked with each E. M. faculty. Ÿ Or Single form ; number rank faculty for each category. Ÿ Or On-line computer-based form. Ÿ Exit interview with clerkship director : Ÿ Focus on best & worst teachers. Ÿ ? what to do if the director is a problem Ÿ Or Exit interview with non-E. M. designee who prepares anonymous report. Ÿ ? require evaluations returned before rotation grade issued

Main Categories Important for Student Evaluations of E. M. Faculty Ÿ Teaching ability / effectiveness Ÿ Interest / enthusiasm in teaching Ÿ Clinical ability (although students’ ability to evaluate this may be limited, and focusing evaluation of the faculty’s interactions with patients may be more reliable) Ÿ Professional behavior Ÿ Role modeling

Analysis of the Student Evaluations of E. M. Faculty Ÿ Need to be co-reviewed by clerkship director & dept. director. Ÿ Important to correlate relative time or caseload for each student-faculty pair. Ÿ Should separate evaluations for EM-bound and non. EM-bound students. Ÿ Correlate with teaching evaluations by residents. Ÿ Use for promotion & tenure needs predetermination. Ÿ Can consider use for faculty teaching certificate or prize.

Teaching E. M. for Medical Students : Summary • Integration of E. M. into the medical student curriculum : – Gives all students important practical knowledge. – Helps draw students to the specialty of E. M. – Offers faculty development opportunities. – Can create early interest in research. – Creates prepared interns and well-developed physicians. • There a number of options to structure evaluation of students on E. M. rotations and their evaluations of their E. M. experience.