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EDUCATIONAL ADVANCE

Integrating Emergency Medicine Principles and Experience Throughout the Medical School Curriculum: Why and How Matthew C. Tews, DO, and Glenn C. Hamilton, MD, MSM

Abstract The management of acutely ill and injured patients is an essential component of medical student education, yet the formal integration of emergency medicine (EM) into the medical school curriculum has progressed slowly since the inception of the specialty. Medical student interest and the number of resident positions in the National Resident Matching Program are higher than any time in the past, yet students often find access to EM faculty and clinical experience limited to a fourth-year rotation. Incorporating EM into all years of the undergraduate medical student curriculum can offer unique educational experiences and enhance exposure to the necessary and recommended knowledge and skills students must attain prior to graduation. Academic emergency physicians (EPs) should advocate our specialty’s importance in their medical school curricula using a proactive approach and actively involve themselves in medical student education at all stages of training. The goals of this article are to describe several approaches for EM faculty to expand medical student exposure to the specialty and enhance student experiences in the core principles of EM throughout the undergraduate medical curriculum. Academic Emergency Medicine 2011; 18:1072–1080 ª 2011 by the Society for Academic Emergency Medicine

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he management of acutely ill and injured patients is an essential component of medical student education. The Josiah Macy Jr. Foundation Report in 1994 charged medical schools and governing bodies with ensuring that ‘‘every medical student has acquired the appropriate knowledge and skills to care for emergency patients,’’ and the Liaison Committee for Medical Education (LCME) states that ‘‘educational opportunities must be available in multidisciplinary content areas, such as emergency medicine …’’1,2 Moreover, the Macy Report recommends that medical students be provided this education ‘‘through educational experiences supervised by appropriately qualified emergency physicians.’’ Since this statement was published, the formal integration of a mandatory emergency medicine (EM) experience into the medical school curriculum has varied from institution to institution, but has progressed slowly.3 At the time of From the Department of Emergency Medicine, Medical College of Wisconsin (MCT), Milwaukee, WI; and the Department of Emergency Medicine, Boonshoft School of Medicine (GCH), Kettering, OH. Received January 20, 2011; revision received March 16, 2011; accepted March 18, 2011. The authors have no relevant financial information or potential conflicts of interest to disclose. Supervising Editor: Mark B. Mycyk, MD. Address for correspondence and reprints: Matthew C. Tews, DO; e-mail: [email protected].

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the Macy Report, only 18% of medical schools had mandatory EM rotations; by 2007 the percentage had only doubled and remains less than 40%.4 A required experience in EM for all medical students remains an important, but distant goal, despite the impressive growth in the number of academic departments and residency programs within academic medical centers over the same time period.5,6 A clear disconnect exists between the significant growth of the specialty as an academic discipline within the academic medical center and the relatively slower integration of mandatory exposure to EM within the medical school curriculum.7 Despite the lack of a required EM rotation in the majority of medical schools, both interest in EM as a specialty and the number of resident positions have risen steadily.8 In the most recent specialty match of 2010, 6.8% of all U.S. medical students matched to EM, making it the third most common specialty choice, with 99% of spots filling.9 In contrast to this rising popularity, students may find access to an EM experience limited to the fourth year.10 A recent survey of EM clerkship directors at residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) found that 65% of institutions accept fourth-year medical students on their EM clerkships, and only 35% allow a clinical rotation for both thirdand fourth-year students.4 While the traditional EM rotation has been in the fourth year, the opportune time to teach EM principles to students and give them an

ª 2011 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2011.01168.x

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Table 1 Essential Skills Offered by Experiences in EM 1. 2. 3. 4.

Basic ⁄ advanced life support Acute care resuscitation Approach to the undifferentiated patient Highly varied clinical experience ⁄ pathology

5. Basic ⁄ advanced procedural skills 6. Leadership, management, diplomacy 7. Unique educational content (i.e., toxicology) 8. Health care system understanding and management 9. Prehospital care 10. Disaster-preparedness and medical readiness Adapted from Russi and Hamilton3

early exposure to EM can begin much earlier in the curriculum. Incorporating EM throughout the undergraduate medical student curriculum offers many unique opportunities to present and reinforce important educational experiences. The range of these experiences was detailed in two 2005 papers by Russi and Hamilton3 and McLaughlin et al.11 and are summarized in Table 1. It is essential that medical students have exposure to these experiences prior to graduation and entering any residency training program. Therefore, it is imperative that academic emergency physicians (EPs) advocate for our specialty’s integration into their medical school curricula. This requires a proactive approach with active involvement in medical student education at all stages of training. The goals of this article are to describe several approaches for EM faculty to expand medical student exposure to the specialty and enhance student experiences in the core principles of EM throughout the undergraduate medical curriculum.

APPROACHES TO INTEGRATING INTO THE CURRICULUM Academic and curricular administrators typically rely on the basic science educators to impart large quantities of factual information before the clinical experience begins. Therefore, it is not common in the traditional medical school curriculum for EM to have a role in formal teaching or course leadership positions during the first 2 years of medical school. In the clinical years, the LCME requires certain experiences of students in ‘‘the disciplines and related subspecialties that have traditionally been titled family medicine, internal medicine, obstetrics and gynecology, pediatrics, preventive medicine, psychiatry, and surgery.’’2 These often take up the bulk of the curriculum in the third year of medical school. Therefore, EM has not historically been included as a curricular priority for medical school curriculum planners. This current situation poses specific problems as a result of the traditional design and historical absence of EM in the curriculum, which limits medical student exposure to ‘‘appropriately qualified emergency physicians’’ and ‘‘educational opportunities … available in multidisciplinary content areas such as emergency medicine.’’1,2 The problems are as follows.

1. 2. 3. 4.

Research and other scholarly activities Multidisciplinary collaboration Fostering independent study and learning Acquiring skills of critical judgment (e.g., evidence-based medicine) 5. End-of-life care 6. Intergenerational care 7. Communication skills 8. Cultural competency 9. Advising and mentoring 10. Training of effective teachers Adapted from McLaughlin et al.11

First, students in their early formative experience interact and build relationships with faculty members whose expertise does not cross into our clinical arena. The ideal medical school curriculum would comprehensively introduce representatives from all specialties and disciplines ‘‘to prepare students to enter any field of graduate medical education.’’2 Additionally, the curriculum ‘‘must incorporate the fundamental principles of medicine,’’ many of which are encountered during everyday experiences in the ED. EPs have many strengths and interests that can be beneficial to all students regardless of specialty choice or year of training (Table 1). Additionally, EM is capable of addressing several LMCE accreditation standards for the medical school as defined by McLaughlin et al.11 Second, students may be selectively exposed to predetermined role models, possibly influencing their specialty choice without the benefit of a reasonably broad awareness about career options. Data have shown that when choosing EM, primary care, or a surgical specialty, medical students are strongly influenced by mentors and role models.12 Not every student for whom an EP serves as a role model for will be interested in EM, but EPs have worked with physicians from all different specialties and are familiar with the benefits and drawbacks of each, making them ideally situated to have a comprehensive understanding of medicine and the ability to assist with career and specialty advice. Combining these strengths with an EM experience that exposes students to clinical decision-making and the management of the highly varied medical conditions presenting to the ED makes EM a unique environment for students to obtain a comprehensive understanding of clinical medicine.7 Third, early experiences start to shape the student’s perspective about what is ‘‘really important’’ in the clinical practice of medicine. While the traditional study of medicine, surgery, and pediatrics is necessary for a proper foundation of medical care, EM can offer complimentary expertise in these topics, but also in topics such as health care systems, difficult socioeconomic challenges, emergency medical services systems, disaster-preparedness, end-of-life care, and cultural competencies. All of these are integral for a more thorough understanding of the medical system3 (Table 1). Finally, the topics and skills of acute care management and decision-making, which are represented by EM are necessary for all medical students. The ability

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to approach the acutely ill or injured patient requires a certain expertise and experience that EM is capable of offering to all students. All of these issues represent the necessary focal points for change. To correct this curricular misalignment, EM educators must pursue opportunities to interact with all medical students throughout the curriculum and optimize the time spent with them. An unwavering consistency and commitment over time is necessary to integrate EM into the curriculum and to bring about change. Five general principles can guide EM faculty in accomplishing this goal: 1. The EM curriculum must be comprehensively planned to include all stages of medical student education while showcasing the unique strengths of the specialty. The primary purpose of a medical school is preparing medical students for graduate (residency) training and ultimately for independent patient care. The LCME has developed accreditation standards for medical schools as a means for achieving this purpose.2 The 2005 Society for Academic Emergency Medicine (SAEM) Undergraduate Education Committee published a review of the most recent updates to these standards and suggested ways EM can help meet these requirements.11 These are summarized in Table 1, but the paper is highly recommended reading. 2. Each EM academic unit must become actively involved in the medical school curriculum planning and evaluation. The curriculum committee structure is the key to integrating the principles of EM into the training and careers of medical students. Curriculum committees change primarily from the inside out and will not spontaneously modify their course offerings to address the strengths of EM unless EPs are positioned to help guide curricular decisions. To have meaningful input, EPs must become involved in faculty-based medical school governance and committee structures. Regardless of the task or committee, EPs’ performance must be deliberate, organized, and of high quality to demonstrate the effect EM can have in attaining quality medical student education. 3. A cadre of EM faculty must be available as medical student advisors. Emergency physicians have a broad perspective of patient care and health care systems and have a wide gamut of experience with many specialties. These experiences allow them to usefully advise students, regardless of their specialty choice. For those students interested in EM, every effort should be made to allow time for student contact given the inherent challenges of around-the-clock shift work. 4. EM faculty must be consummate educators with each and every student encounter. Emergency physicians are adept at working in chaotic environments and can adapt to teaching students in any context. Countless opportunities exist to train medical students in any situation from the bedside to the classroom, and EPs have the versatility to teach a wide range of knowledge, procedures, and skills.13 A consistently positive educational experience with

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EM IN THE MEDICAL SCHOOL CURRICULUM

students in any setting will increase their enthusiasm for medicine and potentially excite them about a career in EM or, at a minimum, help them recognize how EM can benefit their own specialty practice. 5. A cadre of EM faculty must commit to mentoring medical students into the specialty. Successful physicians often have mentors who guided them through their early careers. This is a more carefully planned and committed role than that of ‘‘advisor.’’14 A student benefits from this relationship by relating to someone who encourages and guides him or her in important decisions early and throughout his or her career. Developing a mentoring relationship with medical students may also provide EPs with a sense of personal and career satisfaction.15

INTEGRATING EM PRINCIPLES AND EXPERIENCES THROUGHOUT THE CURRICULUM A consistent exposure to EM throughout the curriculum can greatly influence every student’s perception of the specialty and understanding of its principles. The different stages in which EM can be incorporated into a student’s training are detailed in the following paragraphs. The Premedical College Years When undergraduate students are contemplating careers, they typically know little about medicine. While TV shows such as ‘‘ER’’ have brought EM into mainstream public knowledge, they are no substitute for the real practice of medicine, and the premedical years are an opportune time for the first-time exposure to EM. Survey data from the Association of American Medical Colleges (AAMC) reported by matriculating medical students shows the majority of students often make the career decision about entering medicine by the end of their first 2 years of college, some even before high school.16 Several factors have a positive influence on their decision to study medicine, including individual physicians, health-related work experience, and a health professional advisor. The impressions students form in this ‘‘premed’’ period can have significant influence on their decisions regarding careers in medicine. There are many ways to engage undergraduate students. First, many colleges and universities have student organizations, clubs, or interest groups for ‘‘careers in medicine.’’ Most clubs welcome guest speakers, and premedical advisors are often willing to provide educational speakers for their students. Topics may include the basics, such as ‘‘getting into medical school’’ or ‘‘maintaining a life while becoming a physician,’’ as well as more sophisticated subjects like ‘‘the impact of health care reform on the quality of patient care and physician life.’17 Most students benefit from ‘‘shadowing’’ a physician while preparing to apply to medical school. The emergency department (ED) is an ideal place to expose them to medical practice and demonstrate the clear effect medicine can have on patients. Commonly, students who have shadowed a physician will ask for a letter of recommendation, and this offers another opportunity to discuss career choices.


Students often desire research experiences to enhance their medical school applications. EM has a vast array of potential research topics, allowing for early involvement in research, as well as a unique perspective of clinical medicine. Involvement in EM research provides students the opportunity to learn about research, but also allows exposure to the clinical environment. EM also offers research topics outside the clinical setting. Some topics include health policy, injury prevention, simulation training, international EM, and prehospital care.18–22 One of the biggest benefits for students who participate as research assistants in an academic associate program through their school is the higher rate of medical school acceptance.14 Finally, EPs can become involved in the medical school’s formal admission process, either by interviewing or as part of the admissions committee helping to forge a good first impression of the medical school and EM. The Medical School Years Medical school is traditionally divided into two parts, the first and the second biennium. The first biennium commonly emphasizes the basic science, clinical skills, and clinical correlations. The second biennium typically places the student in clinical settings and offers graduated patient care responsibilities. The First Biennium. The first biennium is a seminal time for EM faculty to be involved in medical student education. Interaction with students can be scheduled as part of their introduction to the fundamentals of medicine, including history and physical examination

Table 2 Opportunities to Engage Medical Students in EM: The First Biennium Orientation Didactic lectures Radiology Electrocardiogram course Basic Life Support ⁄ Advanced Cardiac Life Support Physical diagnosis Clinical case correlations for any basic science course e.g., Anatomy, physiology, pharmacology High-fidelity simulation Ultrasound training e.g., Basics, clinical applications Procedural workshops Skills labs for suturing, airway management Clubs and organizations Emergency medicine interest groups Lectures Clinical Observational shifts School physicals Community service Free clinics Medical school service Committees Administration ⁄ dean’s office Advising and mentoring Research Research associate program Social Events

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and basic procedural skills. Students benefit greatly from clinical examples and vignettes at this early stage. This is an ideal time to initiate an understanding of the principles of acute care medicine, often illustrated by ‘‘real-world’’ clinical vignettes. Examples of key contact and teaching opportunities during the first biennium are listed in Table 2 and discussed below. Orientation The introduction of faculty to medical students commonly starts during their orientation. During this time, medical students are given an overview of what to expect during their training while fulfilling requirements for graduation, offered bonding experiences, and introduced to selected faculty. Medical schools provide extensive materials during orientation, including information about departments, interest groups, and activities of which EM should be a component. Many schools have EM interest groups (EMIGs) and a description of this group should be included in the initial materials given to students during orientation.23 Importantly, if EM faculty do not request this inclusion it will not routinely occur. Didactic Teaching The first biennium instruction is typically the responsibility of basic science faculty, with expanded involvement of clinical faculty during the second year. EM faculty should be involved in formal or informal didactic teaching in both years. Some schools use a case-based or team-based learning format, with interaction between a single instructor and small group, and problem-based learning and simulation sessions, as opposed to the traditional didactic, large classroombased experience.24 Given the broad knowledge necessary to practice EM, involvement in the subjects commonly taught during the first biennium is not difficult and may contribute greatly to the education at this level.25 Additionally, EPs are in a position to teach content areas unique to EM. These may include lectures or cases introducing the approach to the undifferentiated patient, specific chief complaints, toxicology, and prehospital care and disaster situations. One of the most relevant areas for EM faculty in the first biennium is teaching clinical correlations for the basic science subjects, e.g., anatomy (head and neck, airway, extremities, and pathologic variants of anatomy, such as trauma) or cellular biology (cellular poisons such as cyanide, carbon monoxide, and aspirin; clinical acid–base disorders). These remain an excellent opportunity to introduce acute care principles into the curriculum and are usually welcomed by basic science educators in their courses of study. These opportunities must be pursued, as basic science faculty will rarely seek out EM faculty for these courses, unless they are known to them. In the second year, classes are commonly organized by organ systems, such as cardiovascular, pulmonary, or gastrointestinal. Many of these offerings deliver ‘‘bread-and-butter’’ topics and clinical correlations appropriate for EM faculty to teach and provide numerous opportunities for EM to present or share didactics with medical students throughout the year. Specific cross-specialty subjects like shock or pain management, or presenting complaints such as altered mental status, abdominal pain, or nausea and vomiting, fit well within the educational realm of EM faculty. Complementary

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topics outside the systems-oriented curriculum can include basic life support; advanced life support; and introduction to radiographs, clinical laboratory, and electrocardiography, as well as continuing the clinical skills development begun in the first year. Incorporating the ‘‘acute’’ aspect of chronic diseases, such as diabetes, asthma, or congestive heart failure, offers a unique perspective to the students not always seen in the primary care setting. High-fidelity Simulation and Task Training Models Medical education is progressively becoming more competencies-based.26–29 Instead of proving they have completed an activity, learners increasingly need to demonstrate their competence in a number of venues.30 The use of high-fidelity simulation and task training models has provided opportunities for learners to demonstrate procedural, professionalism, and communication competence.31,32 Simulation technologies have come to the forefront of competency training in medical education and it is an active research arena.33 Simulation has been used to translate basic science knowledge and concepts into the clinical decision-making environment.34–36 This approach imprints the basic sciences through clinical example, including response to interventions—all at no risk to patients. The enthusiasm of EM educators in adopting this technology has been an important element in the advancement of EM involvement in the medical school curriculum, and its linkage to our specialty should continue.37 (Editor’s note: see the November 2008 issue, open access at http://www.aemj.org, for the proceedings of the Academic Emergency Medicine consensus conference ‘‘Simulation in Emergency Medicine.’’) Procedural Workshops Medical students in the first biennium can be taught through a variety of procedural workshops, (e.g., sterile technique, suturing, basic airway management, and intravascular access). EPs can teach most any procedure a medical student should learn, and a well-organized procedural skills training can become a major strength of EM early in the curriculum.38 These small group settings allow one-on-one interaction with the students and may further secure future opportunities for advising and mentoring. Clinical Teaching In the traditional medical school curriculum, there are usually limited opportunities for students in the first biennium to be involved in clinical activity. Institutions may offer an early clinical experience in which medical students are paired with clinicians to gain exposure to the clinical environment. Shadowing opportunities should be arranged through EMIGs or directly through an academic department or division. Medical schools often participate in school physicals and free clinics, which are a popular opportunity for students to gain early clinical experience. Medical School Service Involvement with medical school committees is an important means of integrating into the school and participating in the day-to-day activities and long-term strategies of the institution. Curriculum, admissions, faculty development, or promotion and tenure committees are groups typically central to guiding medical student education and experience. The EM faculty should collaboratively plan their strategy for committee involvement and actively

seek guidance in the politics and process of attaining committee membership and leadership. Additionally, sponsoring an active EMIG allows for early interactions with students.23 Advising and Mentoring Emergency medicine is a popular career choice for students in U.S. medical schools.5 However, not all medical schools have an academic department or EM residency program to allow interested students access to EPs for career advice. This can affect the number of students choosing EM as a career.6 Additionally, when medical students look for advice about EM from non-EM faculty, they may receive negative advice.39 Advising can be accomplished in a group setting through an EMIG, the student government, or other student clubs.23 For students who attend medical schools without affiliated EM residencies or departments, the Clerkship Directors of Emergency Medicine (CDEM), which is an academy within the SAEM, offers an E-Advisor Program that is an online resource for students who are seeking advice from EM faculty across the country.40 A newer development is the SAEM Emergency Medicine Interest Group Grants, which award money to support medical student educational activities and require EM faculty sponsorship.41 Some students may seek more of a mentorship, which is different than an advisor’s role.15 Mentorship is typically a mutually agreeable relationship where a seasoned physician helps to guide and shape the career of a younger student over a longer term. The presence of a mentor often leads to a more productive and satisfying career, and EPs have demonstrated a clear capability in serving as mentors to medical students. Social Events Involvement in social activities is just as important for student interaction as more formal roles as an advisor, teacher, or mentor. Involvement can begin as early as the white coat ceremony, orientation for first-year students, or a welcome picnic for new students and can continue until the graduation ceremonies and beyond. It is important to purposefully maintain a professional demeanor and attitude, as students closely observe their instructors and teachers outside of the classroom or clinic. Research Students often desire a research project to enhance their applications for residency or as part of their career choice. There is often time between the first and second year to participate in these projects or as paid part-time research assistant positions during the first 2 years. The ED has multiple opportunities for research projects and can provide a variety of studies of interest to students. In addition to clinical topics, the students may explore EM involvement in public health, trauma systems, public policy, palliative care, international disaster relief, and overcrowding issues.18–22

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The Second Biennium. The second biennium traditionally represents the time when students enter the ‘‘core’’ rotations. During this predominantly inpatient-focused experience, students may encounter less than favorable views of the ED, as ED consults and unscheduled admissions translate into additional work for the resident or faculty staff. It is important during this formative time in a medical student’s career that our specialty is accurately represented.


Third Year Experiences in the medical student’s third year traditionally center around the core rotations mentioned above. Third-year EM rotations are uncommon, and mandatory third-year experiences are nearly nonexistent.4 This current status poses two problems for third-year medical students: they are not reliably exposed to the necessary emergency medical conditions and principles until their last year of medical school, and they are limited in their exposure to EM as a career choice until the beginning of their fourth year. An approach for becoming involved in the education of third-year medical students includes developing a thirdyear rotation in EM. It may be accomplished as a stand-alone elective, an interdepartmental experience linked with surgery or anesthesia or EM can advocate for a mandatory clerkship within the medical school. The goal is to establish the opportunity for third-year student exposure to the acute care aspects of medicine commonly encountered in the ED. Fourth Year Emergency medicine faculty typically have a more organized role in the clinical instruction and education of fourth-year students during an EM rotation. Medical students in their fourth year have experience taking histories and performing physical examinations, but most are unaware of acute care decision-making or how to tailor their clinical efforts for efficiency. Overwhelmingly, they do not have adequate procedural skills. Each is a strength of EM.42 EM faculty can offer students insight into patient management and clinical decision-making, as well as guiding them in applying EM knowledge and principles into preparing for the real demands of residency training, and ultimately a professional career, regardless of specialty. Further opportunities include the unique contemporaneous feedback associated with bedside teaching, advancing communication skills with patients and family members, and clinically translating the cultural competency lessons of the classroom to the time-limited clinical setting of the ED. Clinical Setting A rotation in the ED is hard work and may be intimidating and anxiety-provoking for even the most mature students; therefore, expectations for fourth-year students must be clearly defined. For the EM faculty, effective teaching in a busy ED can be difficult, but a few moments conveying a clinical ‘‘pearl,’’ a ‘‘mini-lecture’’ during a shift, or a brief evaluative summary after a shift may substantially affect a student’s experience in patient care.43 A mix of EM resident and faculty teaching is optimal, as it offers both parties some respite from this high-intensity relationship in a highly demanding environment.44 For those students specifically interested in EM, another more advanced rotation may be arranged, such as a subinternship.45 CDEM has published a well-designed fourth-year rotation curriculum that is available as a template for planning the student experience.46,47 There is also an online curriculum available for EM educators planning a curriculum.48 Outside of clinical teaching, there are numerous other opportunities for contact time with students in the second biennium (see Table 3). Didactic Teaching When students are disseminated among numerous rotations or cities during the second

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Table 3 Opportunities to Engage Medical Students in EM: Second Biennium Didactic lectures Resident lectures Student lectures Integrating technology Internet-based education Handheld computer programs Medical simulation Clinical Bedside teaching Procedural skills EM subinternship Journal club participation Medical school service Capstone courses Meet and greet events Advising and mentoring Transition to internship course Residency candidate preparation National organization participation EM interest group Research opportunities ⁄ presentation support Social events Graduation awards ⁄ recognition

biennium, face-to-face didactic teaching becomes difficult. One approach to overcome this barrier is to integrate educational technology into the medical student rotation.49 EPs with technological savvy can find an academic niche in providing educational programs for students and developing resources to be used by the student from any location with a computer or handheld device.50 For physicians in a residency program, lecturing to the residents will provide time with students, since they often participate with resident didactics during their rotation. High-fidelity Simulation and Task Training Models Just as it has value in the early years of training, simulation has a positive effect on students in the second biennium.51 Students at this level typically need help in transforming clinical information into a prioritized differential diagnosis and an immediate patient care plan, and the integration of simulation as part of a rotation helps facilitate this type of learning.52 Additionally, students will benefit by taking leadership roles in a patient care environment and rehearsing the critical decisions they will need to make as first-year residents with real patients.53 Cases involving acute care decision-making run by an experienced EP are a popular method of learning for students and can be made available to students by scheduling practice sessions or as part of a rotation.37 This gives them a chance to make real-time decisions in life-threatening situations without the potential of adverse effects to the patient.54 Medical School Service There are additional opportunities to teach in a formal fourth-year setting at the medical school. Some schools have a ‘‘boot camp’’ or ‘‘transition to internship’’ class that serves as a transition from medical school to residency.55,56 These courses usually teach ‘‘survival’’ skills for working more independently in a hospital or clinic environment.

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For those with a residency program, faculty participation during residency interviews and ‘‘meetand-greet’’ functions can provide an opportunity to discuss the unique aspects of EM as a career. Other services that benefit the medical student include reviewing applying students’ personal statements and conducting a detailed and open discussion of the residency selection list and preparatory interviews with clear feedback on dress, mannerisms, and approach to data gathering and questions. Nearly all students will improve their performance and experience during the interview process with these active interventions.57,58 Opportunities abound for student involvement in EM at the local or national level, either with student organizations or at conferences. EM has numerous student sections, lectures, and events linked to organizations such as the American College of Emergency Physicians (http://www.acep.org/), the American Academy of Emergency Medicine (http://www.aaem.org), Council of Emergency Medicine Residency Directors (http:// www.cordem.org), and SAEM (http://www.saem.org). Student involvement in these national organizations presents a great opportunity to promote their leadership abilities and raise the visibility of their medical schools.15 Finally, the presence of EM at noncurricular functions, such as graduation, shows commitment and caring by the EM faculty. Graduation is an important transition in the student’s life, and a time for recognition. EM must be part of that recognition structure. It represents the final offering an EM faculty may make to the medical student’s education, even without a formal clerkship or a role in the medical school administration.

• The ratings of the medical student EM rotation must be closely monitored. Student feedback is a direct pathway to improvement and enhanced satisfaction over the long term.

MEASURES OF SUCCESS Applying the suggestions made in this article while actively integrating EM into the medical school will take time, and the defined effects may take several years. Parameters for success must be measured: • Contact hours with students should be monitored. These data will give the academic EM unit and the medical school administration a tally of the actual hours a student’s educational experience is taught by EM. • Students should complete evaluations after any EM event, such as a lecture, a simulation session, or clinical rotation. The goal is to demonstrate the effectiveness of instruction from the student perspective. These are valuable data for negotiating additional exposure time within the curriculum and for promotion purposes. • Recognition for educational success for EM faculty should be actively pursued and broadly acknowledged. ‘‘Teacher of the Year’’ awards or their equivalent are proof of effective teaching and influence on the education of medical students. • The results of the match for the EM residency must be monitored at each institution. Performance data should include a comparison with the number of students selecting EM at your school versus nationally and the number of students matching to EM who remain at your institution.

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CONCLUSIONS Integrating EM into the career stages of medical students is necessary to offer a complete education for all medical students that involves acute care decisionmaking, procedural skills, and many other topics unique to our specialty. Establishing the presence of EM in the medical school curriculum is not an easy task. EPs must actively advocate for and incorporate EM into the medical school curriculum and into everyday interactions with medical students. This article has outlined and described specific opportunities for doing so and certainly more opportunities exist at each institution. Once EM is established in the medical school, it is imperative to monitor and measure its success. The goal is to consistently demonstrate to administrators that EM offers an essential learning experience for each student and has a positive effect on the quality and relevance of the education and future career development of each student. References 1. Macy J Jr. The role of emergency medicine in the future of American medical care. Ann Emerg Med. 1995; 25:230–3. 2. Liaison Committee on Medical Education (LCME). Functions and Structure of a Medical School. Available at: http://www.lcme.org/functions2010jun.pdf. Accessed July 17, 2011. 3. Russi CS, Hamilton GC. A case for emergency medicine in the undergraduate medical school curriculum. Acad Emerg Med. 2005; 12:994–8. 4. 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. 5. National Residency Match Program [NRMP]. Results and Data: 2010 Main Residency Match. Available at: http://www.nrmp.org/data/resultsanddata2010. Accessed July 17, 2011. 6. Gallagher EJ, Goldfrank LR, Anderson GV Jr, et al. Role of emergency medicine residency programs in determining emergency medicine career choice among medical students. Ann Emerg Med. 1994; 23:1062–7. 7. Wald DA, Lin M, Manthey DE, Rogers RL, Zun LS, Christopher T. Emergency medicine in the medical school curriculum. Ann Emerg Med. 2010; 17:S26–30. 8. Newton DA, Grayson MS. Trends in career choice by US medical school graduates. JAMA. 2003; 290:1179–82. 9. National Residency Match Program [NRMP]. Data and Reports. Available at: http://www.nrmp.org/ data/index.html. Accessed July 17, 2011. 10. Zun LS, Downey L. Is a third year clerkship in emergency medicine correlated with a career


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