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ACADEMIC EMERGENCY MEDICINE
NOV 1997
VOL 4 / N O 1 1
Emergency Medicine in the Medical School Curriculum Louis J. Ling, MD. L. Thompson B o d e s , MD, PhD, Richard Reynolds, MD, Louis Kroot, MD, Paul Roth, M D
LOUIS J. LING, MD At the Association of American Medical Colleges (AAMC) annual meeting in November 1982, Dr. John Bernard Henry, Dean of Georgetown School of Medicine, said, “Young physicians need to feel confident of handling medical and surgical emergencies. You strike at a need for every medical student. The need to manage less urgent problems can be delayed, but the emergencies must be handled by the individual present. Every medical school graduate should possess at least a rudimentary competence in the management of medical and surgical emergencies. For the most part, this subject is currently limited to the emergency department.. . . Given the background of curriculum content overload in our medical schools today, is emergency medicine going to become part of the problem or part of the solution?’’ In 1980, the University Association for Emergency Medicine (UAEM), the Society for Teachers of Emergency Medicine (STEM), and the American College of Emergency
’
...
. ..
I
TABLE 1 Is There a Required Emergency Medicine Clerkship in the Curriculum? .. ...... ..... .. . . . . . . . . ,... ......... ......, .... . . . . . ......,....... .... . Required Clerkship
MD-granting schools Year 3 Average no. weeks Year 4 Average no. weeks
7 (6%)
,..
N o Required Clerkship 107 (94%)
3 14 (13%)
100 (87%)
4
DO-granting schools Year 3 Average no. weeks
5 (67%) 4
10 (33%)
Year 4 Average no. weeks
14 (93%) 4
1 (7%)
Physicians (ACEP) published a set of guidelines to direct student education.2 In 1985, STEM extracted from the core content,’ which defines the breadth and scope of emergency medicine (EM), the portions of the knowledge base and skills list that would be appropriate for medical student^.^ In 1987, the Academic Affairs Committee of ACEP suggested that in the first year, Basic Cardiac Life Support (BCLS) be required, with 10 hours of didactic emergency aid-type lectures.
.
From Hennepin County Medical Center; Minneapolis, MN (LJL); the National Board of Medical Examiners (LTB); the Robert Wood Johnson Foundation ( R R ) ; the University of Kentucky, School of Medicine. Lexington, KY ILK); and the University of New Mexico, School of Medicine, Albiryuerqrie. NM (PR). Received: March 20, 1997; accepted: March 27, 1997. Prior preseiimtion: Association of American Medical Colleges annual meeting, Washington, D C , October 1995. Address f o r correspondence and reprints: Louis J. Ling, MD, Associate Medical Director f o r Medical Education. Hennepin County Medical Center; 701 Park Avenue, Minneapolis, MN 55415. Fax: 612-904-4401; e-mail:
[email protected]
.
In the second or third year were 24 hours of problem-oriented lectures such as chest pain, shortness of breath, abdominal pain, environmental emergencies, and how to work with the emergency medical services (EMS) system, followed by an elective clerkship in the third and fourth years.’ In 1990, SAEM developed a curriculum that included goals, references, and topics for discussion, and then suggested areas for demonstration, laboratory, and bedside teaching.6 How well are we doing? In 1994, in preparation for the Macy Foundation conference,’ a survey was sent to the dean’s offices of 126 allopathic and 16 osteopathic schools, with 114 allopathic and 15 osteopathic respondents. Of those 114 allopathic schools, about 20% have a required clerkship (Table l), about the same number as in 1985 when Sanders et al. surveyed the schools.* Nearly all (97%) the allopathic schools have an
EM in the Medical School Curriculum, Ling
I
TABLE 2 Are Elective Clerkships in Emergency Medicine Available in the Curriculum? .............................................
MD-granting schools Year 3 Year 4 DO-granting schools Year 3 Year 4
Yes
No
82 (72%) 111 (97%)
32 (28%) 3 (3%)
7 (46%) 12 (80%)
8 (54%) 3 (20%)
elective clerkship in EM, as do 80% of the osteopathic schools (Table 2). That is much higher than 1982, but similar to the 90% in 1985.7 Almost all the schools teach BCLS or CPR, although only 80% require it (Table 3). Advanced Cardiac Life Support (ACLS) is very common, but Advanced Trauma Life Support (ATLS) is much less common. Forty percent require knowledge of airway intubation, and only 52% teach vascular access. Splinting, cervical spine immobilization, and gastric lavage are required in about a fourth of the allopathic schools. The osteopathic schools are much more likely to require these skills. The skills are taught primarily in the clinical years 3 and 4. Emergency physicians (EPs) frequently forget that there are other disciplines involved in teaching EM (Table 4). In 1994, EM was usually part of another department (Table 5). The average medical school had 10 full-
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TABLE 3
et
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time EPs and 9 of those 10 were board-certified in EM (Table 6). In 1994, the Josiah Macy Jr. Foundation sponsored a conference addressing “The Role of Emergency Medicine in the Future of American Health Care.” During that conference there was considerable discussion regarding e d ~ c a t i o n . ~Kay Clawson suggested that “emergency medicine specialists not necessarily teach every class bearing on their area of expertise, but define what needs to be taught and then decide who can teach it most effectively and efficiently. Instead of fighting for required time, emergency medicine should concentrate on providing good electives.” A recommendation was made that state medical licensing boards, the National Board, the Liaison Committee on Medical Education (LCME), and medical school deans and faculty must ensure that every medical student has acquired the appropriate knowledge and skills to care for emergency patient^.^ This education must be provided through educational experience. as supervised by appropriately qualified EPs. To give us advice and insight into how to implement that, we invited this panel to help us. We were fortunate that the Macy Foundation had the wisdom to invite Dr. Thompson Bowles to chair the Macy conference. He is president of the National Board of Medical Examiners (NBME) and was previously
Emergency Medicine Skills in the Curriculum (Number of Schools)
.......................................................................................
Skill Taught Skill* BCLSICPR ACLS ATLS Airway intubation Vascular access Splittinglimmobilization Cervical spine immobilization Gastric lavage
MDt 107 (94%) 91 (80%) 30 (26%) 97 (85%) 98 (86%) 92 (81%) 88 (77%) 85 (75%)
Skill Required MD
Dot 15 (100%)
15 (100%) 3 14 14 14 3
(20%) (93%) (93%) 193%) (87%) 9 (60%)
92 49 9 44 59 32 27 28
(81%) (43%) (8%) (39%) (52%) (28%) (24%) (25%)
DO 15 13 2 12 13 11 10 7
(100%) (87%) (13%) (80%) (87%) (73%) (67%) (47%)
*BCLS = Basic Cardiac Life Support: ACLS = Advanced Cardiac Life Support; ATLS = Advanced Trauma Life Support. tMD-granting schools ( n = 114); DO-granting schools ( n = 15).
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TABLE 4 Disciplines Involved in Teaching Emergency Medicine Content and Skills ....................................
Specialty Emergency Medicine Surgery Internal Medicine Family Practice Anesthesiology Pediatrics
I
No. MDgranting Schools
No. DOgranting Schools
101 65 29 20 16 13
15
11 8
TABLE 5 Organizational Status of Emergency Medicine ..........................................
Separate department Part of a departmenusection or division No departmenuunit Other unit
No. MDgranting Schools
No. DOgranting Schools
39 52
5 6
17 6
4
Dean of George Washington University School of Medicine.
L. THOMPSON BOWLES, MD, PhD Reaction to medical emergencies is unevenly taught i n American medical schools. Medical students pick up a good deal of EM by integrating several unplanned and disconnected clinical experiences during their third and fourth years of medical educationcardiac arrest in the recovery room, a serious trauma patient in the ED, a baby with a high fever in admitting. However, exposure to such patients is sporadic and it is inconsistent among classmates. Many educators now believe, and the Macy report advocates, that at graduation every medical student should be capable of effectively approaching patients with a medical emergency, even if it is unrealistic to maintain that skill for an entire medical career. Every medical student needs a broad medical school education to share a common language, a
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TABLE 6
ACADEMIC EMERGENCY MEDICINE
Number of Emergency Physicians (EPs)
No. Full-time EPs
Average Range
No. Full-time EPs Board-certified in Emergency Medicine
MD-granting Schools
DO-granting Schools
MD-granting Schools
DO-granting Schools
10 (0-42)
5 (0-34)
9 (0-27)
5 (0-34)
common generalist experience, and a tion in basic life support skills and usable ability to identify and respond training in emergency situations can to dangerous conditions outside of enhance student confidence, emphathose in the specialty field. While size the importance of knowing basic some knowledge and skills will di- science, and begin preparing students minish over time, some common abil- for clinical work. The episodic emerities should nevertheless be shared by gency experience in regular clerkall graduates. Dermatologists and ships is valuable because students can psychiatrists should know how to im- learn about the management of a mymobilize a fracture, how to compress ocardial infarction from a cardioloa hemorrhage, how to establish an gist, about a diabetic crisis from an airway, when to call for help, and internist, or about the management of how to keep a patient comfortable a stab wound from a surgeon. Howand quiet until help arrives. The pub- ever, a systematic approach to rapid lic assumes that all physicians possess diagnosis, immediate support, and these skills. Medical outcomes so of- early management of the emergency ten depend on rapid, appropriate ac- patient is best learned from a welltion, and the public’s perception is trained and experienced EP. A required clinical experience in the ED justified in this case. As a thoracic surgeon, I believe should be a part of every student’s inthat I can deal with many emergency structional program. State legislatures and state medisituations effectively, but I know that there are other situations in which an- cal boards are well within their public other physician would be better in responsibilities to seek assurances providing care and teaching others to from medical faculties that medical provide such care. Fully educated EPs graduates have been adequately preare the only specialists trained to deal pared to deal with the public’s needs, with this wide range of situations and including emergency care. The should be involved in the planning of United States Medical Licensing Exgeneral medicdl education, including amination (USMLE) regularly inresponse to emergencies. Their partic- cludes questions about EM in all 3 ipation in this planning is the best steps, particularly in steps I1 and 111, way to ensure that a general medical which are entirely clinical in their deeducation includes the approach to a sign. By inclusion of certain quespatient with an emergency condition, tions on the examination, the faculty and an EP should be on the curricu- members who determine the examilum committee of every medical nation content demonstrate their recognition and respect for a topic’s imschool. portance. For the examinees who As the basic sciences are studied cannot pass the examinations, I can in the first 2 years, corollary clinical experiences can enrich learning and assure you that such individuals demonstrate why the basic sciences would not be safe providers of indeare essential preparation for clinical pendent medical care. A Macy conference recommenpractice. During this time, participa-
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VOL 4/NO 1 I
dation advised the establishment of an academic department in EM.’ As a former dean, I harbored some ambivalence with the recommendation, knowing the implications of costly academic initiatives. I resented these imposed measures in my own days when something would be decided that was going to cost money and add to the current problems of the school. Nevertheless, I became convinced that the shortage of EPs and the growing need for their contribution to safe medical care and a generalist education mandated the creation of a department in the specialty. In many institutions the creation of any new department will take several years. Many schools have very effective divisions of EM and have a strong case for retaining its divisional status. However, the recommendation serves as a pressure on the policy issue and I stand by its importance and conclusion. In this contentious period of turmoil and uncertainty, there is little question that departmental status is the strongest position for an academic program in the daily competition for budget and space. If one believes that a medical discipline needs greater authority in planning education and attracting resources for medical practice, departmental status is the strongest position for achieving that goal. Although in many institutions, it may take many years to develop. Of course, departmental status carries with it the need for an active research program and productive clinical activity.
Question (Bill Robinson, MD, University of Missouri, Kansas City, MO): Dr. Bowles, you alluded to the issue of evaluation-driven curriculum. Will we be able to get specific feedback as to whether the students are doing well on the EM portions of the USMLE? Answer (L. Thompson, Bowles, MD, PhD): Yes, with one caveat. Where the old NBME had about 900+ questions on each part, now USMLE uses
EM in the Medical School Curriculum. Ling et ul.
around 700 questions. The number of questions in all of the subgroups is far smaller and the new examinations d o not yield optimal subject feedback as much as the old examinations did. EM questions are combined with 2 or 3 other categories, which comprise only 10-15% of the step I1 and 111 questions. We can yield profiles to schools, not only on individual students, but o n their students’ performance by subject.
LOUIS LING, MD The Robert Wood Johnson Foundation has a longtime interest in medical education, generalism, and curriculum development and redesign. We are very pleased to have the Executive Vice President from the foundation, Dr. Richard Reynolds, to give us his perspective.
RICHARD REYNOLDS, MD My involvement in EM dates back to , the local the late 50s’ and ~ O S ’ when physicians staffed the ED with a daily on-call schedule. As an internist, I was expected when on call to be the first physician to review inpatients of all ages with all types of problems. As new doctors entered the community, trained in surgery, medicine, obstetrics and gynecology, or pediatrics, this was obviously not a comforting way to practice, either for us or for the patients. In the past 2 decades, EM has emerged as a recognized discipline. The driving force has been that skilled doctors are required to administer the ever-increasing sophisticated technology, often lifesaving, that is no longer the purview of the everyday practicing physician and simultaneously. third-party reimbursement has made it possible for hospitals to hire full-time EPs. Today’s question is “Why hasn’t EM become a major staple of undergraduate education?” Curriculum reform is one of those issues that is greatly talked about, but very little is done about. Since the Flexner Report
in 1910, there have been at least 20 or so major task forces or commissions to address this subject, and 5 since 1991. Christakis9 reviewed these proposals and found them strikingly similar. Their themes most often encourage the medical school curriculum to serve the public interest, address workforce needs, cope with burgeoning knowledge, enforce lifelong learning skills, and foster generalism. The conclusions are to train more generalists, adopt clinical education programs in community and ambulatory settings, take advantage of more sophisticated pedagogy such as simulated patients and computer interactive learning, and increase smallgroup discussions. There should be fewer lectures, integration of basic and clinical teaching, increasing emphasis on the interplay between medicine and society, and a better understanding of human behavior. There is a simultaneous push to reduce the overcrowding of the curriculum. Medical curricula have been compartmentalized but, for most faculty, the balkanization has been favorable. Anatomists taught human structure; pediatricians taught child health. The student was on his or her own to integrate these subjects. This has been less than ideal and certainly, the development of molecular and cellular biology has blurred the boundaries among the basic science departments. The health of many of our citizens is impaired by a group of morbidities, mental illness, substance abuse, AIDS, teenage pregnancy, fragile elders, and violence, which transcend any one department or discipline. Schools actively engaged in curriculum reform are discovering that integration of some clinical teaching units may be necessary. Many of the educational needs of the clinical departments are best taught in primary care settings. Emergency medicine provides an important interface for students to learn subjects that are common to each discipline; the use of technology in supporting badly damaged or
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acutely ill patients, the ethics of initiating life-support services, and the fit of EM into the total spectrum of health care. There is also overlap between patients seen in the ED and those seen in primary care practice, including the use of the ED by many underserved as the entry into the health care system. This is not ideal care, but it is today’s reality. In the 60s’ there was a comparable movement to make family medicine a respected discipline in medical education. Organized family physician constituencies established board certification for their members, developed residencies. and struggled to develop academic units within medical schools. The leaders of family medicine were able to convince the public at large that the dearth of general physicians was detrimental to their health. Medical schools, however, were reluctant to change because faculty included few general physicians and most believed that increasing specialization was necessary to understand and deliver ever-increasingly sophisticated care. Family physicians bypassed the usual method of change i n medical education and took their issue to the state legislatures. Soon, many states with public medical schools passed laws requiring the establishment of academic units of family medicine. The federal government folIowed with faculty development grants and awards t o schools that fostered departments of family medicine. In 1992 and 1993, 9 states passed legislation impacting on medical schools, in most instances, to train more primary care physicians. Some went so far as to cap specialty training programs, some to favor admission of students who practice in medically underserved areas, and some to include s u c h subjects as public health, preventive medicine, and health care delivery in a medical school curriculum. This is alarming, as it portends even more external influence on the character of medical education, but public medical schools have little
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TABLE 7
ACADEMIC EMERGENCY MEDICINE
Objectives
up or^ completion of the rotation, srudeiirs shorild be able to.
Pcrfonn Advanced Cardiac Life Support Demonstrate competence in the initial assessment and disposition of the following medical emergencies: I. Abdominal pain 1. Chest pain .$. Coma 4. Febrile child 5. Extremity pain 6. Headache 7. Myocardial infarction X. “Nerve problems” 9. Shortness of breath 10. Syncope 11. Vaginal bleeding Demonstrate skill in the performance of the following procedures: 1. Airway management 2 . Application of splintskasts 3. Arrhythmia recognition 4. Lumbar puncture 5 . Megacode 6 . Placement of Foley catheter 7. Use of slit lamp and tonometel 8. Venous access Demonstrate knowledge of the management of the following medical emergencies: 1. Anaphylaxis 2. Bites 3. Epistaxis 4. Near-drowning 5. Sexual assault
choice except to comply. I do not endorse this legislative intervention, but as far as family medicine is concerned, it has been a powerful force in changing the curriculum of medical schools. ‘The story of academic family medicine has similarities to EM. The perceived need for EPs, the development of residencies and board certificat.ion, and the establishment of departments and divisions of EM follow a parallel course. EM has tried to make its impact, however, by working within the system. Why is change, that seems so logical to some, so difficult? In 1990, the Robert Wood Johnson Foundation sponsored a Lewis-Harris poll of 1,400 medical educators, including deans, faculty, and department chairs. In the poll, 61% of the medical educators believed medical education needed fundamental changes or thor-
ough reform, and 51% thought this true of their own institutions. The majority of deans and administrators favored reform. The chairpersons of basic sciences and their faculty were the most reluctant to change. Against this backdrop, one might think that change would occur. Most medical schools, however, have decentralized governance of their curricula; it is usually relegated to a curriculum committee composed of representatives of the major departments. To foster institutional recognition for their faculty and programs, departments often want to stake out a curriculum territorial claim. However, if you gain time and place, someone else loses time and place. Curriculum committees tend to protect the status quo, rather than initiate change. What does this mean for the future of undergraduate medical education in EM? EM faculty must be-
NOV 1997 VOL 4/NO 1 1
come involved in overall curriculum reform, not just advocates for your portion. EM faculty should become involved i n the school’s administration. You should favor a more centralized governance of curriculum, for only then will change be more rational and in tune with student and society needs. You should support collaboration with other departments in teaching EM because there is considerable overlap, and I think you should be relentless.
Question (Louis Ling, MD): It seems EPs are not core parts of medical school faculties. Is it recognized by medical schools that there is a place for EPs i n curriculum planning? Answer (Richard Reynolds, MD): It is taking place. It took family medicine 20-25 years to get to where it is, partly because of the difficulty of curriculum committees to bring something new into the fold. My plea for you is to become active and aggressive in the administration of the medical school, sit on the curriculum committee, just don’t let it go. I don’t know if the answer is 3 weeks of EM or integration of EM into the other disciplines. It doesn’t matter where you get started. Just get started and let the thing play out as you experience it. Question (Arlo Weltge, MD. University of Texas, Houston, TX): I sit on the curriculum committee at the University of Texas, Houston, and I have experienced the frustration of trying to make a change and the inability to make that change. Can you describe centralized curriculum planning a little better and how that actually works as an agent of change? Answer (Richard Reynolds, MD): It works in different ways, according to each medical school. There is a group of people who accept the assignment of curriculum overview, who have the trust of the administration and the trust of the faculty.
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EM in the Medical School Curriculum, Lirzg et a/.
I . ,TABLE 8 Course Implementation , . .. ., . .... . . .. . . . .. . . ... .
-
.
.
.
... .
.
..
. . . . . ...... . . . . . .
Four-week rotation during fourth year First 6 days in didactic lectures, clinical skills workshops, and Advanced Cardiac Life Supportl Basic Cardiac Life Support certification Next 21 days require 10 clinical shifts and 1-2 emergency medical services shifts at one of 14 clinical sites in central/eastern Kentucky Final day, return to academic medical center for examination Text: Hamilton GC, Sanders AB, Strange GR, Trott AT (eds). Emergency Medicine: An Apuroach to Clinical Problem Solvine. Philadelohia: W. B. Saunders. 1991.
I
TABLE 9
Results (Based on 1994-1995 Academic Year. First Year of Course)
Positive Highest-rated course in University of Kentucky College of Medicine Voluntary, community-based faculty rated very favorably Dr. Teresa Johnson voted best fourth-year preceptor by senior class (emergency medicine faculty member) High correlation between patient care experience at academic and community sites (rho correlation = 0.89) N o overall difference between examination performances by students based on rotation site CbalIetiges Communication of expectations with faculty across a wide geographic area Preceptor development needs: student evaluation Deliberate efforts to include voluntary faculty in planning and to communicate benefits of teaching Development of new clinical sites and adding voluntary faculty: many paper.work requirements
Someone has to make sure that what they come up with after all review and input is something binding. At the Foundation, as we get proposals, the plans for curriculum change are wonderful. The question, of course, is implementation.
Question (Mark Henry, MD, State University of New York at Stony Brook, NY): I am concerned about the generalist training of the cadre of doctors who are going to be the gatekeepers. Family medicine may have some breadth of exposure, but in our institution, internists or pediatricians are not getting training in splints or vascular access or other things outside of their vertical training. I also wonder where family physicians in training get exposed to undifferentiated illness and highly acute patients? Answer (Richard Reynolds, MD): The only place to get the training for
undifferentiated acute emergency care is in the ED. I have no argument over that or the fact that students should have this experience.
LOUIS LING, MD The idea that our patients can be seen in different settings is important because it points out a strong need for collaboration, more than in other specialties. The ideal place to teach emergency care may not be the same from institution to institution. Dr. Reynolds has mentioned the non-EP perspective. Our next 2 speakers both happen to be EPs. Dr. Kroot is the Educational coordinator in EM at the University of Kentucky, one of the places that Dr. Reynolds mentioned as having successfully reformed their curriculum. The University of Kentucky is one of those 20% that have a required clerkship in EM. How have you wisely invested that responsibility of time?
LOUIS KROOT, MD Kentucky is a predominantly rural state. T h e dean has been sensitive to the manpower requirements from around the state and when he asks the rural hospitals what they need, they say “1) We need primary care physicians. 2) We need emergency physicians.” Many small hospitals have family practitioners and general practitioners manning their emergency rooms after hours. We have difficulty importing qualified EPs to staff the EDs throughout the state. Likewise, in the rural environment many patients are seen in practitioners’ offices who ordinarily would be referred to an ED. So, there is recognition of the practice environment that necessitated a basic foundation in EM. We have a 4-week period for students, and I focus on the critical elements (Table 7). I look at the most common complaints the students would have to deal with in the ED. The first 6 days are didactic and the next 21 days have 10 10-hour clinical shifts and 1 to 2 EMS shifts. We use 14 community based hospitals throughout the state and this has worked o u t extremely well (Table 8). The word has gotten out to students, “You don’t want to go to the university. You want to work at a community center because you don’t have to fight for cases with the resident or the intern. You do not have to wait in line and you have one-on-one teaching with an EP.” Didactic teaching is done ahead of time so we provide students with the core body of knowledge, which has made the clinical course well received by the community-based faculty. We have a sheet with the number of patients and types of complaints seen, which the students fill out during their clinical shifts. There was 90% correlation between problems they see in community hospitals and at the university. More important, on the final examination, there is no difference in how these students do (Table 9). Coordinating the education
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provided by our community-based faculty required central oversight.
LOUIS LING, MD The specialty has finally grown enough to have its own dean and Dr. Roth will give that perspective. Prior to that, he was a Division Chief and the first Chair of Emergency Medicine at the University of New Mexico
PAUL ROTH, MD Deans are talking about how medical schools will continue their educational and research mission i n an environment of heavy competition. At the University of New Mexico, 25% of our budget comes from the state and 60% from patient revenue. That drives how we make decisions. We are facing the prospect of downsizing and eliminating whole programs. As academicians, we are having to reassess our social contract, while as clinicians, we’re reevaluating our relationship to our patients. These are extremely difficult times. As a dean, I am more favorable to faculty who come to me expressing a desire to participate in problem solving as team players. to help ensure the institution’s existence and to preserve the basic values of our profession. To press the issue that EM is a critical force and in its own right must be given more political power within the schools of medicine will only set up an antagonistic relationship with the dean, the rest of the leadership, and the other faculty. It is also extremely contrary to where the rest of academic medicine is headed today. Successful schools of medicine are centralizing, not decentralizing. They are creating interdisciplinary group practices and tearing down departmental barriers, not reinforcing them. Undergraduate medical education has undergone reform much earlier than the economic reform we are facing today. These new curricula are geared to produce undifferentiated graduates with a generalist orienta-
ACADEMIC EMERGENCY MEDICINE
tion. Much of this originated at the University of New Mexico and is focused on student-centered, problembased learning methodology. A student now has a lot more to say about his or her own learning than he or she would in the traditional system. Learning is in small tutorial groups where specific patient cases are discussed from the first day of medical school. Basic biomedical sciences and clinical information is learned throughout the full 4-year period, not as disciplines of pharmacology, internal medicine, and EM, although there are, and should be, rotations through those specialties. Faculty, both basic science and clinical, serve as tutorial leaders who guide the discussion and ensure that the content areas are covered. It is important to distinguish between teaching the medical students EM and teaching them how to manage emergencies. With this background, let me suggest how EM faculty can increase their participation as members of a school of medicine faculty. First, I believe strongly that emergency faculty are generalists capable of participation in all levels of learning experiences for the health professions. We can serve as mentors to students and participate in a variety of bioethical, psychological, social, and other public health discussions. As members of the faculty, we should be participating in curriculum planning and redesign toward a generalist orientation. Those who participate are doing so as faculty members, not because they carry the title of EP, internist, or surgeon. Second, EM faculty do possess specialized skills, particularly in resuscitation of medical and surgical diseases. These skills can be called upon during the learning experiences of medical students, particularly during the latter 2 years. Finally, the most characteristic feature of EM is our approach to clinical problem solving. This coincides with the basic tenets of problembased learning methodology. The patient presents to the ED, not with
NOV 1997 VOL 4/NO 1 1
acute appendicitis or pelvic inflammatory disease, but with abdominal pain. The way we as EPs think is the way we are now encouraging learning. This makes EM faculty extremely valuable in this new undergraduate medical curriculum. Individual faculty must be advocates for those whom we serve: our students. colleagues, patients, and schools of medicine. We must be seen as team players with the rest of the faculty and assume ownership of the dilemmas facing our institutions. Deans and other members of the medical leadership will then be compelled to place us in key positions. Respect and influence will then follow and EM should flourish, not only within the institution, but nationally. Question (Bill Robinson, MD): Dr. Reynolds, I am curious if you got your money’s worth out of your investment and whether Robert Wood Johnson has any further plans to try to stimulate this sort of change in medical schools. Answer (Richard Reynolds, MD): Did we get out money’s worth? Probably the biggest value of our grant to these schools is that it places medical education on a higher plane. These 8 schools now network and these people can share their successes, struggles, and failures. Other schools consult them. Overall, I think the trend is pretty good. Question (Steve Stapczynski, MD, University of Kentucky, Lexington, KY): Medical schools evaluate themselves by how well their students do on standardized examinations. One fear of curriculum reform is if we teach students in a new way, they will not acquire the basic facts that are tested on these standardized examinations. Our board scores, which every school looks at very carefully, will dip when we do curriculum reform. How do you reconcile curriculum reform with results on standardized tests?
EM in the Medical School Curriculum, Ling
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Answer (L. Thompson Bowles, MD, Question (Steve Stapczynski, MD): PhD): The USMLE is put together Given the fact that there had been 15 by faculty members from every fac- or so curriculum reform efforts over ulty in America. At any given time, the last 70-90 years, what do you probably 50-60% of the faculty of think is going to stick from this curthe campuses are represented, from rent effort? Are there fads and fashall disciplines. Currently, I believe ions that will swing one way for the there are 3 EPs on our various com- next 5 or 6 years and then will swing mittees. We probably ought to have the other? What’s going to persist bemore. We have faculty members from yond it? all different specialties, but are leaning toward generalists. The content of Answer (Paul Roth, MD): I am USMLE reflects the content that is very hesitant to predict anything, taught on all campuses. even for Lomorrow. However, what I The standards on USMLE derive would hope to see remain, and what from wide discussion among faculty, appears to be consistent with what I students, licensing boards, and people see as a trend, is an integrated apin practice. The questions and content proach toward the curriculum. The are common and a high percentage of emphasis is on student-centered students at LCME accredited medical learning. I would hope that those schools, 97-98%, end up passing the kinds of things continue because it re3 steps. This is true whether they’ve ally helps all of our students continue come through a problem-based cur- in lifelong learning. riculum or a traditional curriculum. With regard to performance, beWe have so far not identified a cor- fore our new curriculum at the Unirelation between score performance versity of New Mexico, we began the and the curriculum used on campus. primary care curriculum, creating 2 There should be nothing on tracks of students. The data that we USMLE that would discourage your have thus far accumulated regarding trying a new way of teaching medical the performance of our students on students. The vast majority of your the boards corroborate what Tom students are going to do well, but says. We cannot find a statistically there is going to be a small, absolute significant difference between the 2 number of students who will graduate tracks. Students are pretty smart and from U.S. medical schools and will they will learn effectively in most ennever pass the licensing examination. vironments. We are hoping to create It is indeed unfortunate, but it has al- an environment that will help stuways been true. If you have a student dents learn, not only in medical who is unable to pass the USMLE, school, but in residency and beyond. examine the rest of the academic record of the student. Invariably, you are LOUIS LING, MD going to find a student who has struggled academically. The examination In conclusion, we have heard that we is helping to prevent some of those need to be broad-minded and think in individuals from practicing medicine. the interest of the students, not to just
think about EM. We need to be part of the solution to help teach generalists. Participation in this integrated, more centralized planning seems to be the trend. Finally, when we do something, we need to d o it well. I thank all of the panelists for sharing their perspectives and experience. REFERENCES 1. Henry JB. Emergency medicine and the Association of American Medical Colleges (AAMC). A m J Emerg Med. 1983; 1:35-42. 2. American College of Emergency Physicians. Guidelines for undergraduate education in emergency medicine. Ann Emerg Med. 1980; 9:222-8. 3. Emergency medicine core content. J Am Coll Ernerg Physicians. 1979; 8:34-41. 4. Society of Teachers of Emergency Medicine. Core content for undergraduate education in emergency medicine. Ann Emerg Med. 1985; 14:474-6. 5. American College of Emergency Physicians. Guidelines for undergraduate education in emergency medicine. Ann Emerg Med. 1987; 16:117-9. 6. Society for Academic Emergency Medicine. A mo d el pre-clinical, clinical and graduate educational curriculum in emergency medicine f o r medical students and rotating residents. A n n Emerg Med. 1990; 19:1159-66. 7. Bowles LT, Sirica C M (eds). The Role of Emergency Medicine in the Future of American Health Care. New York: Josiah Macy Jr. Foundation, 1995. 8. Sanders AB, Criss E, Witzke D. et al. Survey of undergraduate emergency medical education in the United States. Ann Emerg Med. 1986; 15: 1-5. 9. Christakis NA. The similarity and frequency of proposals to reform US medical education. Constant concerns. JAMA. 1995; 274: 706-1 1.
Key words: emergency medicine; medical education: funding; health care reform.
