732743, 2015
Copyright 2015 Elsevier Inc.
Printed in the USA. All rights reserved
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http://dx.doi.org/10.1016/j.jemermed.2014.12.063
Education
IMPLEMENTING A THIRD-YEAR EMERGENCY MEDICINE MEDICAL
STUDENT CURRICULUM
Matthew C. Tews, DO, MS,* Collette Marie Ditz Wyte, MD, Marion Coltman, MD, Kathy Hiller, MD,
Julianna Jung, MD, Leslie C. Oyama, MD,k Karen Jubanyik, MD,{ Sorabh Khandelwal, MD,#
William Goldenberg, MD,** David A. Wald, DO, Leslie S. Zun, MD, Shreni Zinzuwadia, MD,
Kiran Pandit, MD, MPH,kk Charlene An, MD, MSC,{{ and Douglas S. Ander, MD##
*Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, Department of Emergency Medicine, Oakland
University, William Beaumont School of Medicine, Royal Oak, Michigan, Department of Emergency Medicine, University of Arizona Health
Network, Tucson, Arizona, Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, kUCSD
Emergency Medicine, University of California, San Diego, San Diego, California, {Department of Emergency Medicine, Yale-New Haven
Hospital, New Haven, Connecticut, #Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, Ohio,
**Department of Emergency Medicine, Naval Medical Center, San Diego, California, Department of Emergency Medicine, Temple University
School of Medicine, Philadelphia, Pennsylvania, Department of Emergency Medicine, Mount Sinai Hospital, Chicago Medical School,
Chicago, Illinois, Department of Emergency Medicine, New Jersey Medical School-University Hospital, Newark, New Jersey, kkDepartment
of Emergency Medicine, Columbia University, New York, New York, {{Department of Emergency Medicine, SUNY Downstate Medical
Center, Brooklyn, New York, and ##Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
Reprint Address: Matthew C. Tews, DO, MS, Department of Emergency Medicine, Medical College of Wisconsin, 9200 W Wisconsin Avenue,
Milwaukee, WI 53226
INTRODUCTION
Emergency medicine (EM) offers medical students a variety of clinical experiences that are directly applicable to
their future careers, regardless of specialty choice (1,2).
Students completing an EM rotation encounter acutely
ill and injured patients with complaint-based presentations. They learn the evaluation and management of the
733
734
Should-Can model allows for placement at any point during the third year, adaptation for the experienced versus the
novice student, shorter rotations, inter-specialty or longitudinal EM experiences and multi-site rotations (19,20). The
third-year syllabus was designed to be a distinct entity
from the fourth-year medical student curriculum.
After publication of the syllabus, the Work Group
drafted learning objectives for all curricular content. Using the Delphi approach, Work Group consensus was obtained for the Must objectives through a series of
online surveys. The Should and Can learning objectives were refined in the same way as the Must objectives.
Given the wide variety of potential third-year curricula
in existence, the Work Group sought input from thirdyear rotation directors external to the Work Group to
assess the content validity of the curriculum. CDEM
members were contacted via the CDEM list serve to identify third-year rotation directors willing to participate in
an online survey. Thirteen rotation directors responded
to the inquiry and each was sent an anonymous online
survey. Of the 13 respondents, 11 completed the survey,
representing a mix of student experience that include
elective, selective, and mandatory rotations ranging
from 2 to 6 weeks in length.
Step 3: Goals and Objectives
Curriculum goals for the third-year student.
1. To gain exposure to EM principles and practice.
2. To understand the signs and symptoms of the
acutely ill or injured patient.
3. To become familiar with the initial evaluation of a
broad variety of medical and surgical emergencies.
4. To develop a differential diagnosis based on lifethreatening causes of common chief complaints.
5. To develop an approach to the initial resuscitation
and management of the undifferentiated patient.
6. To begin to develop the knowledge, skills, and attitudes necessary for the practice of EM.
Learning objectives and core curriculum.Table 1 lists the
Must learning objectives derived from the Work
Groups consensus recommendations, and outlines the
core curriculum content, including potential educational
and assessment methods, with correlations to the
Accreditation Council for Graduate Medical Education
competencies, the American Board of Emergency Medicine Milestones and the Entrustable Professional Activities for graduating medical students (15,16,21). Each
content area is associated with a CVI based on the
survey responses of the external third-year rotation di-
M. C. Tews et al.
Content
CVI
1.00
Stabilization of the
Acutely Ill Patient
0.82
Vital Signs
1.00
0.64
Educational
Methods*
Assessment
Methods
ACGME Competencies,
ABEM Milestones,
and EPA
References
L, IS, Podcast
C, G, SOE, MCQ,
Sim, OSCE
PC-1,2,3,5,6
MK
EPA-10
L, IS
C, G, OSCE, Sim,
SOE, MCQ
PC-1,2,3,4,5,6,10
MK
EPA-10
L, IS
PC-1,5,6,10
MK
EPA-10
L, S, EL
C, G, Sim, MCQ
PC-1,4,5,6,10
MK
EPA-10, 12
735
Continued
Content
736
Table 1. Continued
CVI
1.00
Chief Complaint
Differential
Diagnosis
1.00
Diagnostic Testing
1.00
Electrocardiogram
(ECG)/Rhythm
Recognition
0.82
Assessment
Methods
ACGME Competencies,
ABEM Milestones,
and EPA
References
L, IS, C, S,
EL, SG
C, G, OSCE, Sim,
SOE, SP, MCQ,
EOS, BE, DO
PC-2
MK
PBLI
PROF-1,2
EPA-1
L, C, E, SG, S, IS
C, Sim, SOE,
MCQ, EOS
PC-2, 3, 4
MK
PBLI
EPA-2
L, C, SG, Sim, IS
C, Sim, SOE,
MCQ, EOS
PC-3
MK
SBP-2,3
EPA-3
L, IS, S, EL
C, Sim, SOE,
MCQ, EOS, BE
PC-3,4
MK
EPA-10
M. C. Tews et al.
Focused Chief
Complaint History
and Physical (H&P)
Examination
Educational
Methods*
1.00
0.82
Documentation
0.64
Disposition
0.82
Emergency Medicine
within the US Health
Care System
0.82
Professionalism
1.00
L, IS, C, S, EL
C, G, L, Sim,
SOE, MCQ,
EOS, BE
PC-9,13
MK
EPA-12
L, IS, C, SG
PC-11
MK
ICS
EPA-12
L, C, S, SG
PC-2,6
MK
ICS
SBP-3
EPA-5
L, IS, C, S, SG
PC-7
MK
ICS
SBP-2
L, IS, SG
SOE, MCQ
MK
PBLI
SBP-2
L, IS, R, C, S
C, G, OSCE, RR,
SOE, SP, MCQ,
EOS, BE
ICS
PROF-1,2 SBP-1
EPA-9
Continued
737
Emergency
Department (ED)
Procedures
738
Table 1. Continued
Content
CVI
Communication
0.80
Motivation
1.00
Educational
Methods*
Assessment
Methods
ACGME Competencies,
ABEM Milestones,
and EPA
References
L, IS, R, C, S
C, G, OSCE, RR,
SOE, SP, MCQ,
EOS, BE
PBLI
ICS-1,2
PROF-1, 2
SBP-1,2
EPA-9
IS, R, C
C, G, L, RR, EOS
PC-6
MK
PBLI
EPA-7
M. C. Tews et al.
ABEM = American Board of Emergency Medicine; ALS = advanced life support; BLS = basic life support; CDEM = CDEMcurriculum.org; CVI = Content Validity Index; ED = emergency
department; EMCP = Emergency Medicine Clerkship Primer; EPA = Entrustable Professional Activities; PALS = pediatric advanced life support; SDOT = standardized direct observation
assessment tool.
* C = clinical ED setting; E = E-learning; IS = independent study/reading; L = lecture; R = reflection; S = simulation; SG = small group sessions.
C = checklist evaluation of live or recorded performance (e.g., SDOT, Mini-Clinical Evaluation Exercise); BE = bedside evaluations; DO = direct observation; EOS = end of shift evaluations; G = Global rating of live or recorded performance; L = procedure or case logs; MCQ = written examination; OSCE = objective structured clinical examination or standardized
patients; P = portfolios; RR = record review; S = patient surveys; Sim = simulations and task trainers; SOE = standardized oral examination.
ICS = interpersonal and communication skills; MK = medical knowledge; PBLI = practice-based learning and improvement; PC = patient care; PRO = professionalism; SBP = system-based
practice; PC-1 = Emergency Stabilization; PC-2 = Performance of a Focused History and Physical; PC-3 = Diagnostic Studies; PC-4 = Diagnosis; PC-5 = Pharmacotherapy; PC-6 = Observation
and Reassessment; PC-7 = Disposition; PC-8 = Multi-tasking; PC-9 = General Approach to Procedures; PC-10 = Airway Management; PC-11 = Anesthesia and Acute Pain Management; PC-12 =
Goal Directed Focused Ultrasound; PC-13 = Wound Management; PC-14 = Vascular Access; MK = Medical Knowledge; PROF-1 = Professional Values; PROF-2 = Accountability; ICS-1 = Patient
Centered Communication; ICS-2 = Team Management; PBLI = Practiced Based Performance Improvement; SBP-1 = Patient Safety; SBP-2 = Systems Based Management; SBP-3 = Technology.
EPA 1 = Gather a history and perform a physical examination; EPA 2 = Develop a prioritized differential diagnosis and select a working diagnosis following a patient encounter; EPA 3 =
Recommend and interpret common diagnostic and screening tests; EPA 5 = Provide documentation of a clinical encounter in written or electronic format; EPA 7 = Form clinical questions
and retrieve evidence to advance patient care; EPA 9 = Participate as a contributing and integrated member of an interprofessional team; EPA 10 = Recognize a patient requiring urgent or
emergent care, initiate evaluation and treatment, and seek help; EPA 12 = Perform general procedures of a physician.
k Objectives that cover both pediatric and adult resuscitation principles. ACGME = Accreditation Council for Graduate Medical Education; US = United States.
739
(24). Recent work has further defined the content for a pediatric EM clerkship curriculum (25). Although the Work
Group did not delineate pediatric-specific content, the objectives that are relevant for both adult and pediatric content are identified in Table 1.
Step 4: Educational Strategies
The core of any educational EM rotation is the clinical
experience, however, the number and duration of shifts
will vary, depending on the resources of the institution
or department (4,12). During their clinical time,
students should be exposed to the structure and
function of the ED, learn the approach to patients with
a variety of chief complaints, and begin to understand
diagnosis and basic management principles for
undifferentiated acutely ill or injured patients. This
approach is fundamentally different from that used for
the fourth-year student, who is expected to have experience with the basic approach to common complaints and
is focused on honing higher-level diagnostic and management skills (6). The difference in experience and
acumen between third and fourth-year students is a
particular challenge for institutions that offer EM experiences for both groups. Clinical educators must take
care to modify their expectations based on the students
level of training, and adjust their teaching accordingly.
Simulation (29,30,4244,4549)
Reflection (31,32,50)
Lecture (21)
Positive Aspect
Electronic
Interactive
Learn at own pace
Creates a virtual environment
Requires little personnel time
Team-based/problem-based learning
Promotes discussion and clinical reasoning
Higher level of application
Promotes independent thought
Replicates clinical environment
Procedural/task training
Standardized scenarios
No risk of harm to patients
Ideal clinical exposure for novice students
Effective for teaching communication and
teamwork
Can be oral or written
Leads to meaningful learning
Formative or summative
Helps promote self-awareness of students
beliefs, values, and attitudes
Efficient
Large amount of information in short time
Consistent coverage of objectives
Large audience reached
Can be done by podcast/electronic media
asynchronously
Student sets own pace
No need for direct faculty involvement
Can be delivered electronically
Negative Aspect
Significant start up expense
Large amount of time to create
Costly
Time consuming
Heavy personnel commitment
Requires institutional resources
740
Step 5: Implementation
New rotation directors may take on the daunting task of
creating or redesigning an EM experience, often with
minimal guidance or direction. In addition to building
skills in teaching, curriculum development, and student
assessment, rotation directors must be familiar with the
practical aspects of overseeing a rotation (5153). They
must know and follow their institutional policies and
national standards (22). Specific LCME requirements
supported by this curriculum are listed in Appendix 3,
which may serve as a resource for educators negotiating
the initiation of a mandatory EM clerkship within their
medical schools.
There are several resources available to assist with implementation. One is the Guidebook for Clerkship Directors produced by The Alliance for Clinical Education,
which is a comprehensive resource for clerkship directors
across specialties (54). The Clerkship Coordinators
Handbook can provide guidance on administrative duties
for the rotation (55). Kerns Curriculum Development in
Medical Education: A Six Step Approach provides a practical and systematic way to approach the implementation
phase of a curriculum (14). While Kern outlines a broad
range of factors that must be taken into account when implementing a curriculum, potential barriers to success
merit special consideration.
Possibly the biggest challenge is teaching students
with differing levels of clinical experience, depending
on the timing of the rotation during the third year. Faculty
and residents involved in teaching medical students may
require guidance in adjusting their expectations and practices to meet the needs of learners in various stages of
their training. We chose the Must, Should, Can model
to allow for this flexibility while maintaining consistency
in teaching the core aspects of EM (Must). Novice
learners in the ED must be provided with close supervision to ensure patient safety.
A second challenge is time constraints in the ED
setting. Third-year students may require more faculty
and resident guidance than more experienced fourth-year
students. They may not have the clinical experience
needed to evaluate acuity or independently manage certain
aspects of patient care. Balancing the clinical and educational missions of the department is essential, and educators may need to advocate for resources to ensure
adequate teaching for their students without compromising
departmental operations. Faculty and residents involved
with teaching may also require instruction on how to incorporate education for the novice learner into their clinical
work in an efficient and effective manner.
Third, EM education focuses on high-acuity presentations and stabilization procedures. While it is possible to
offer a conceptual background on these topics through
M. C. Tews et al.
741
742
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743.e1
Vital Signs
Educational Methods*
1. Demonstrate how to
L, S, EL
perform electrical cardioversion in the appropriate clinical setting.
2. Demonstrate how to
perform transcutaneous
pacing in the appropriate clinical setting.
1. Perform a focused H&P L, IS, C, S, EL, SG
for a patient presenting
with:
a. Headache
b. Focal neurologic
deficit
c. GI bleeding
d. Vaginal bleeding/
pelvic pain
e. Toxic ingestion
L, C, E, SG, S, IS
ACGME Competencies,
ABEM Milestones, and EPA
References
PC-1, 2, 3, 4, 5, 6, 7
MK
PC-1
MK
C, G, Sim, MCQ
PC-1,4,6, 9
MK
ICS-2
PC-2
MK
PBLI
PC-4
MK
PBLI
Continued
M. C. Tews et al.
Assessment Methods
Content
Diagnostic testing
Electrocardiogram (ECG)/
Rhythm Recognition
Educational Methods*
ACGME Competencies,
ABEM Milestones, and EPA
References
PC-3
MK
SBP-1, 2, 3
PC-3,4, 5
MK
SBP-1
PC-9, 13
MK
SBP-1
743.e2
Laboratory studies
L, C, SG, Sim, IS
1. Describe the indications
and uses of the
following laboratory
studies, and what is
considered normal vs.
abnormal:
a. Arterial blood gas
b. D-dimer
c. Quantitative b-HCG
Radiographic studies
1. Discuss the use of clinical decision rules for
determining which patients with traumatic
brain injury require a
noncontrast head
computed tomography
(CT) scan
2. Interpret a noncontrast
CT scan of the head for
the different types
(epidural, subdural,
subarachnoid, intraparenchymal) of intracranial
bleeding
Bedside testing
1. Describe the indications
and interpretation of a
stool guaiac test for a
patient with potential GI
bleeding
1. Identify the following
L, IS, S, EL
rhythms on ECG or
rhythm strip and
describe their initial
treatment:
a. Supraventricular
tachycardia
b. Atrial fibrillation
c. Atrial flutter
d. Second- and thirddegree heart block
1. Discuss the manageL, IS, C, S, EL
ment of a subcutaneous
abscess
2. Discuss the indications
and contraindications of
a lumbar puncture for a
patient with a headache
Assessment Methods
Appendix 1. Continued
Documentation
(when applicable)
PC-1, 3, 4, 9, MK
ICS-2
SBP-1, 2
PC-3,14
MK
PBLI
PC-2, 6
MK
SBP-2,3
Continued
M. C. Tews et al.
Disposition
743.e3
Content
Educational Methods*
Professionalism
Communication
Motivation
1. Demonstrate follow
IS, R, C
through on admitted patients hospital course
Assessment Methods
ACGME Competencies,
ABEM Milestones, and EPA
References
SOE, MCQ
PC-1
MK
PBLI
SBP-2
EMCP: Chapters 1:
Introduction to the Specialty
of EM and Chapter 4: Unique
Educational Aspects of
Emergency Medicine and
Chapter 5: Differences
between the ED, the Office
and the Inpatient Setting
CDEM: Emergency Medicine in
the US Healthcare System
PC-1, 2, 3, 4 MK
ICS-1, 2 PROF-1, 2 SBP-1, 2
PC-1, 6, 7
PBLI
ICS-1,2
PROF-1, 2SBP-2
C, G, L, RR, EOS
PBLI
PROF-1,2
SBP-2
743.e4
ABEM = American Board of Emergency Medicine; ALS = advanced life support; ACGME = Accreditation Council for Graduate Medical Education; BLS = basic life support; CDEM =
CDEMcurriculum.org; EMCP = Emergency Medicine Clerkship Primer; EMTALA = Emergency Medical Treatment and Labor Act; EPA = Entrustable Professional Activities; HCG = human
chorionic gonadotropin; PALS = pediatric advanced life support; STEMI = ST segment elevation myocardial infarction; US = United States.
* C = clinical ED setting; E = E-learning; IS = independent study/reading; L = lecture; R = reflection; S = simulation; SG = small group sessions.
C = checklist evaluation of live or recorded performance (e.g., SDOT, Mini-Clinical Evaluation Exercise); BE = bedside evaluations; DO = direct observation; EOS = end of shift evaluations; G = Global rating of live or recorded performance; L = procedure or case logs; MCQ = written examination; OSCE = objective structured clinical examination or standardized
patients; P = portfolios; RR = record review; S = patient surveys; Sim = simulations and task trainers; SOE = standardized oral examination.
ICS = interpersonal and communication skills; MK = medical knowledge; PBLI = practice-based learning and improvement; PC = patient care; PRO = professionalism; SBP = systembased practice; PC-1 = Emergency Stabilization; PC-2 = Performance of a Focused History and Physical; PC-3 = Diagnostic Studies; PC-4 = Diagnosis; PC-5 = Pharmacotherapy; PC-6
= Observation and Reassessment; PC-7 = Disposition; PC-8 = Multi-tasking; PC-9 = General Approach to Procedures; PC-10 = Airway Management; PC-11 = Anesthesia and Acute Pain
Management; PC-12 = Goal Directed Focused Ultrasound; PC-13 = Wound Management; PC-14 = Vascular Access; MK = Medical Knowledge; PROF-1 = Professional Values; PROF-2
= Accountability; ICS-1 = Patient Centered Communication; ICS-2 = Team Management; PBLI = Practiced Based Performance Improvement; SBP-1 = Patient Safety; SBP-2 = Systems
Based Management; SBP-3 = Technology.
EPA 1 = Gather a history and perform a physical examination; EPA 2 = Develop a prioritized differential diagnosis and select a working diagnosis following a patient encounter; EPA 3 =
Recommend and interpret common diagnostic and screening tests; EPA 5 = Provide documentation of a clinical encounter in written or electronic format; EPA 7 = Form clinical questions
and retrieve evidence to advance patient care; EPA 9 = Participate as a contributing and integrated member of an interprofessional team; EPA 10 = Recognize a patient requiring urgent or
emergent care, initiate evaluation and treatment, and seek help; EPA 12 = Perform general procedures of a physician.
Appendix 1. Continued
743.e5
Vital Signs
Basic and Advanced Life
Support Techniques
Electrocardiogram (ECG)/
Rhythm Recognition
Educational Methods*
Assessment Methods
ACGME Competencies,
ABEM Milestones, and EPA
References
PC-1, 5, 6
MK
C, G, Sim, MCQ
PC-10
MK
Current BLS/ACLS/PALS
guidelines
CDEM: Basic and Advanced
Life Support
PC-3
MK
SBP-2,3
PC-3,4,5
MK
PC-9,12,14
MK
M. C. Tews et al.
Documentation
Disposition
Emergency Medicine within
the US Healthcare System
PC-1,2
MK
SBP-2,3
PC-3,14
MK
PBLI
SOE, MCQ
MK
PBLI
SBP-2
SOE, MCQ
PC-1
MK
PBLI
SBP-1,2
EMCP: Chapters 1:
Introduction to the Specialty
of EM and Chapter 4:
Unique Educational
Aspects of Emergency
Medicine and Chapter 5:
Differences between the
ED, the Office and the
Inpatient Setting
CDEM: Emergency Medicine
in the US Health Care
System
CDEM: Emergency Medicine
in the US Health Care
System
Continued
743.e6
Traumatic/Orthopedic Injuries
Content
Professionalism
Communication
Motivation
Educational Methods*
Assessment Methods
ACGME Competencies,
ABEM Milestones, and EPA
References
743.e7
Appendix 2. Continued
ABEM = American Board of Emergency Medicine; ALS = advanced life support; ACGME = Accreditation Council for Graduate Medical Education; BLS = basic life support; CDEM =
CDEMcurriculum.org; EMCP = Emergency Medicine Clerkship Primer; FAST = focused assessment with sonography in trauma; PALS = pediatric advanced life support; US = United
States.
* C = clinical ED setting; E = E-learning; IS = independent study/reading; L = lecture; R = reflection; S = simulation; SG = small group sessions.
C = checklist evaluation of live or recorded performance (e.g., SDOT, Mini-Clinical Evaluation Exercise); BE = bedside evaluations; DO = direct observation; EOS = end of shift evaluations; G = Global rating of live or recorded performance; L = procedure or case logs; MCQ = written examination; OSCE = objective structured clinical examination or standardized
patients; P = portfolios; RR = record review; S = patient surveys; Sim = simulations and task trainers; SOE = standardized oral examination.
ICS = interpersonal and communication skills; MK = medical knowledge; PBLI = practice-based learning and improvement; PC = patient care; PRO = professionalism; SBP = systembased practice; PC-1 = Emergency Stabilization; PC-2 = Performance of a Focused History and Physical; PC-3 = Diagnostic Studies; PC-4 = Diagnosis; PC-5 = Pharmacotherapy; PC-6
= Observation and Reassessment; PC-7 = Disposition; PC-8 = Multi-tasking; PC-9 = General Approach to Procedures; PC-10 = Airway Management; PC-11 = Anesthesia and Acute Pain
Management; PC-12 = Goal Directed Focused Ultrasound; PC-13 = Wound Management; PC-14 = Vascular Access; MK = Medical Knowledge; PROF-1 = Professional Values; PROF-2
= Accountability; ICS-1 = Patient Centered Communication; ICS-2 = Team Management; PBLI = Practiced Based Performance Improvement; SBP-1 = Patient Safety; SBP-2 = Systems
Based Management; SBP-3 = Technology.
EPA 1 = Gather a history and perform a physical examination; EPA 2 = Develop a prioritized differential diagnosis and select a working diagnosis following a patient encounter; EPA 3 =
Recommend and interpret common diagnostic and screening tests; EPA 5 = Provide documentation of a clinical encounter in written or electronic format; EPA 7 = Form clinical questions
and retrieve evidence to advance patient care; EPA 9 = Participate as a contributing and integrated member of an interprofessional team; EPA 10 = Recognize a patient requiring urgent or
emergent care, initiate evaluation and treatment, and seek help; EPA 12 = Perform general procedures of a physician.
M. C. Tews et al.
743.e8
Appendix 3. Liaison Committee on Medical Education Requirements Addressed by Third-Year Emergency Medicine
Curriculum* (22)
LCME
Implication
ED-1
ED-1A
ED-3
ED-8
ED-19
ED-27
ED-30
ED-31
ED-34
* Since submission of this article, the Liaison Committee on Medical Education has modified their standards. The new standards publication is effective for the 2015-16 academic year and has a useful table that compares these 2014-15 standards to the updated standards.