Article review: New assessment method for medical students - A Script Concordance Test

What different ways can we assess learners?

This fascinating study assesses a new tool - Script Concordance Test (SCT).

Assessing clinical reasoning skills in scenarios of uncertainty: Convergent validity for a Script Concordance Test in an Emergency Medicine clerkship and residency

What are Scripts?

Scripts are organized networks of knowledge. Integrating them improves decision making. Using scripts, experts see associations while novices struggle with causality. In ambiguous cases, experts process multiple scripts with influx of new information.

What is the format of a Script Concordance Test?

The learners are presented with a short clinical vignette with a series of proposed diagnoses and/or plans. The learners are then presented one new piece of information and asked what effect this information has on the proposed diagnoses and/or plans. They score their decisions on a Likert scale, ranging from -2 to +2.

What did this paper study?

An observational study comparing the scores of 4th year med students (n=314) , residents (n=40) and faculty (n=12) on a SCT with scenarios in Emergency Medicine. The student score was compared to USMLE Step 2 score, and resident score with their ABEM in-training exam score.

What were the results?

The SCT scores were able to differentiate students from residents and residents from faculty. 

• Students vs residents: 60% +/- 6.2 vs 70% +/- 5.4
• Residents vs faculty: 70% +/- 5.4 vs 79% +/- 2.9

There was a significant correlation between resident score and ABEM exam score and a modest correlation between student score and USMLE Step 2 score.

What were the limitations?

It is a single centre study. The internal reliability of the assessment tool was suboptimal.

What were the conclusions?

The SCT may be useful in assessing clinical reasoning in uncertain scenarios.

What do I think?

I enjoy the examples given in the paper. While it is different and likely will take some getting used to, it could be a useful assessment tool.

References

Humbert AJ, Besinger B, Miech EJ. Assessing clinical reasoning skills in scenarios of uncertainty: convergent validity for a Script Concordance Test in an emergency medicine clerkship and residency. Acad Emerg Med. 2011;18(6):627-34. .

A faculty's perspective: Doing well on your EM clerkship

To follow-up with Dr. Connolly's post about the Top 10 tips for medical students to rock the EM clerkship rotation, I thought I would post some additional tips. Here are some more pearls:

11. Take ownership of your patients. 
This means that you should take it upon yourself to make sure that your patient's care is stellar, addresses key clinical and social issues, and is timely. Constantly check for your patient's results. Don't be the last to hear of your patient's lab or imaging results. Figure out why there are unexpected delays. Address any psychosocial issues which may hamper your patient's clinical improvement in the ED.

12. Have a learning plan on shift.
It's helpful to yourself and others to have a focused learning plan for each shift. For instance, this might be -- I want to get better at reading plain films. Let the senior resident and attending know. This fulfills two purposes. First, you'll likely get pulled in to view and read films even though they might not involve your patient. Usually the senior resident or attending will keep a lookout for interesting findings. Second, this shows that you are an active learner who is seeking out learning opportunities rather than letting them passively and randomly occur.

13. Don't be late to your shift.
'Nuff said.

14. In addition to trauma shears, carry a very bright pen light. 
A bright light source comes in handy all the time. I use a bright LED pen light and I constantly use it on shift. This works well especially when trying to examine for laceration, foreign bodies, and other such injuries.

15. Befriend the nurses.
This is a good general rule of thumb for everyone. The nurses are a key part of the medical team and have great clinical gestalt about what is going on with the patients. Introduce yourself to them at the start of your shift. Listen seriously to their concerns and comments. They are a wealth of wisdom and can help answer many of your questions.

16. Clean up your sharps and equipment after procedures.
This is a corollary to rule #15.

17. Start learning about bedside ultrasonography.
This bedside tool is constantly being used in the Emergency Department an. Read up a little on the more common types of ultrasound exams. The most common are probably vascular ultrasounds for central line access and the FAST exam. If you can, try to get some hands-on experience on your cases. Hey, maybe your learning plan for one of your shifts might be to become more adept at bedside ultrasonography!

Good luck to the new MS4 medical students!

An intern's perspective: Doing well on your EM clerkship

It's that time of year again. When medical students interested in EM are stressing over doing well on their EM rotation.

Here's a very insightful guest post from Dr. James Connolly, who is a new PGY-1 resident at Hahnemann Hospital in Philadelphia, and hosts his own blog at: www.erjedi.com. I'll write my personal top-10 list next week, from the perspective of a faculty member.

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Many MS4 interested in emergency medicine will be starting their EM Sub-I's in the next few weeks and are naturally wondering what to expect, and how they can be successful, both in terms of getting a strong letter of recommendation, and all while still having a fun and enjoyable rotation. With that in mind, I'd like to present a unique "Top Ten" list, written with the aim of helping the student succeed on his or her upcoming rotation. The list is my own, based on my experiences during three EM rotations last year as a medical student.  I've also asked a few of my fellow interns for their input on the list, so the list really reflects thoughts of a handful of people who recently successfully matched into emergency medicine. 

1. Case files or a similar book will cover 99% of what you need to know.  But remember, this is not like a medicine rotation where you can go home and read about your patient at night and then use what you learned the next day on your patient.  Avoid UpToDate if you need to look something up as it will give you WAY more information that you probably need. Instead, there should be a copy of Tintinalli's Emergency Medicine or even better "5 Minute Emergency Medicine Consult" laying around to look up something quick if you need to.

2. If you had to know three cases cold, know about chest pain, belly pain and asthma, the differential and basic treatment of each. You will probably see each of these on every shift. There are also a few "rules" that if you know them, you'll be on your way to all-star status. The ones I was asked about most were rules for head CT imaging, C spine clearance, and PERC scoring for pulmonary embolism.

3. Don't worry about trauma, no one has expectations for you to know much, if anything, about what to do when a trauma patient rolls in.

4. Despite that, still gown up for trauma. You might be able to get involved, you might not. But if you don't wear your uniform, the coach can't put you into the game.

5. Keep a pair of trauma shears in your back pocket. Helping to cut clothes is a great way to get up to the table during trauma cases, and you'd be surprised how often you'll need a pair of scissors during your shift.

6. Practice your instrument ties and simple interrupted sutures ahead of time and feel confident knowing how to do them.

7. Before presenting your patient, take 2 minutes and practice it to yourself.  Remember that these presentations are different than your medicine presentations. What the patient had for breakfast or the last time they pooped probably don't need to be included.

8. Practice your presentation. Its worth repeating. In the busy ER, the amount of "face time" you get with those who will be evaluating you largely consists of you presenting your patients, especially during a busy shift.  This is the best opportunity to show your stuff, so if you can appear polished, it will only help. If you present to the attendings, try to run it by your third-year resident first for an additional practice run.

9. When you present, be prepared to answer the question "So what do you want to do?" In other words, have a plan in mind of how you want to proceed with this patient.

10. Review the basics of normal EKGs. You will likely be asked to interpret several EKGs, most of which will likely be normal. Thus,  know what makes an EKG normal (ie Sinus rhythym, regular rhythm, correct intervals and timing etc etc)

Bonus point: Enjoy the rotation. In all of med school, no other rotation will let you be an independent thinker (and often worker) like your EM rotation will. Use this as a chance to apply all that great knowledge you've been building up over the years.

Read more on tips for success from a faculty perspective.

Hot off the press: Nominate someone for a CDEM award

CDEM was born here.

In its third official year, the Clerkship Directors in Emergency Medicine (CDEM) organization is still growing strong. It all started with six of us at an informal dinner in Boston about 5 years ago. And now the organization has grown so large that it is now for the first time offering annual awards to its members.

Know an award-worthy educator? Nominate him or her!

CDEM Clerkship Director of the Year Award
This award recognizes an Emergency Medicine Clerkship Director that has made significant contributions to either a 3rd or 4th year EM rotation. To be eligible for this award, the nominee must currently be a Clerkship Director of a mandatory, selective or elective rotation and have served in that role for a minimum of 5 years. This award is presented at the annual CDEM meeting.

CDEM Young Educator of the Year Award 
This award recognizes a medical student educator at the Clinical Instructor or Assistant Professor level and less than 10 year from residency completion who has made significant contributions to teaching and educating medical students.  This award is presented at the annual CDEM meeting.

CDEM Distinguished Educator Award 
This award recognizes a medical student educator at the Associate Professor or Professor level who has made significant contributions to and has demonstrated sustained excellence in teaching and educating medical students for 10 or more years. This award is not presented annually; rather, it is bestowed on special occasions.

CDEM Award for Innovation in Medical Education
This award recognizes a medical student educator at any faculty rank who has made a significant and innovative contribution to undergraduate medical education. This award is presented at the annual CDEM meeting.

Deadline: Mon, March 14, 2011.

Instructions on how to nominate someone for a CDEM Award can be found at the CDEM/SAEM Website.

Hot off the press: Medical Student Educator's Handbook

It's finally here! 

The second edition to the Medical Student Educator's Handbook is finished.

Here's the info from the CDEM website:

The first edition of this book, titled Medical Student Educator’s Handbook, edited by Drs. Douglas Ander, Wendy Coates, and David Manthey, was developed by the Society for Academic Emergency Medicine (SAEM) Undergraduate Medical Education Committee and Medical Student Educator’s Interest Group. In 2008, Clerkship Directors in Emergency Medicine (CDEM) was formed as an academy within SAEM. CDEM is now the national voice of emergency medicine clerkship directors and medical student educators.

This book represents the collaborative efforts of CDEM members to update the previous edition. The goal of this book is to assist EM faculty interested in medical student education in their efforts to develop a more successful emergency medicine clerkship based on highlighted best practices. This book is intended to offer the reader tools to deal with the challenges of running a successful EM clerkship, including addressing administrative and political considerations, promoting faculty, supporting faculty involvement, determining methods for evaluation, and developing novel teaching tools. We envision its use as a reference for up-to-date, practical information.

Oh, and did I mention that it's FREE!? It's a great reference for educators, chief residents, and anyone interested in academics. Congrats, Rob and Siamak (editors-in-chief).

Download the Medical Student Educator's Handbook

(2 MB)

Computer simulation DIEM case goes live!

Welcome to the new age in medical education for EM!

I've been working on building these interactive, online simulation cases for CDEM for the past 2 years. Finally, the pilot case (a patient with chest pain) is finally out! EM medical students across the country are trying their hand at diagnosing and managing the patient. Preliminary data shows that the case is easy to navigate and students enjoy the ability to make decisions autonomously.

This is the first case in a series called "Digital Instruction in Emergency Medicine", or DIEM cases. These cases allow the user to navigate through a variety of patient complaints and presentations. Similar to high-fidelity simulation, these cases are dynamic, contain multimedia content, and provide a realistic approach to patient management; however in contrast, users can complete these cases anytime and anywhere. All you need is internet access and a computer with Flash capability.

The DIEM modules are especially unique in several ways:

• There is a timer built into the cases to enhance a sense of realism.
• Many parts of the physical exam are displayed for the user to interpret (rather than telling the user what was found).
• When ordering laboratory tests, each test must be justified.
• At the end of each case, the user is required to write up the Emergency Department chart. Documentation is a crucial skill, which medical students often do not get to practice enough in the age of Electronic Medical Records.
• Similar to true simulation exercises, case debriefing is just as important as participation in the case. There is a debriefing section for each DIEM module, which includes an area for self-reflection, a discussion of Critical Actions, and the "ideal" chart writeup.'

It really helps to watch the short instructional video above to help you navigate the case. You'll need about 45-60 minutes for the whole case (if you include the chart writeup and all of the debriefing info that follows the case).

Go to the DIEM case on Chest Pain

The DIEM cases will all live on the CDEM Curriculum site, which also houses the online EM textbook available for free. This was written by CDEM faculty members for the senior medical student level.

Article review: Pitfalls in writing test questions

Which is the best answer?

• A. Yes
• B. No
• C. Maybe
• D. 2 of the 3 above
• E. None of the above

Wait, what?! 

What a terribly written test question! 

Have you encountered similarly poor questions on exams? It turns out that writing multiple-choice test questions is actually pretty difficult. There are some basic rules to follow and pitfalls to avoid.

In an article, the authors (hey, I know most of them! Wait, why wasn't I invited?!) talks about the lack of a National Board Medical Exam in Emergency Medicine. Such "shelf exams" exist in other specialties but in EM. Frankly, it has to do with how expensive it is for medical schools and clerkships to purchase these tests. Within EM, 59% of clerkships are using an end-of-clerkship exam, most of which are designed by the local institution.

The authors also provide an excellent review on the art of writing multiple-choice test questions.

So what are the basics in writing a good multiple-choice test question?

There are 2 parts to each test item:

1. The stem: The question itself
2. The answer choices: Keyed response (correct answer) vs Foils/Distractors (wrong answers)

The Stem

• The test question should be clear and answerable without looking at the possible choices.
• The test question should have only one undisputable answer.
• Avoid being too wordy. State the question concisely.
• Avoid "negative" questions (eg. Which of the following is NOT a cause for...)

The Answer Choices

• There are smart test-takers out there. For instance, choices which have the word "always" or "never" are usually foils and thus incorrect answers. Grammatically incorrect choices are usually wrong. When choosing between 2 answers, the really long one is often the right choice, because the test-writer wants clarify and ensure that the answer is correct. Be aware of these when writing the keyed response and foils.
• When listing the choices, put the responses in logical order (alphabetical or numerical).

The authors also discuss the importance of determine test reliability and content validity. Are the students performing poorly because you just suck at writing test questions? Perhaps a better solution than having all the clerkships working in isolated silos is to have a single validated exam.

Thus, the authors conclude the need for a standardized, national EM final exam, now that a formal EM curriculum has been created by CDEM this past year.

Reference
Senecal E, Askew K, Gorney B, Beeson M, Manthey D. Anatomy of a Clerkship Test. Acad Emerg Med, 2010, 17: S31-37. DOI: 10.1111/j.1553-2712.2010.00880.x
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Article review: Importance of first clinical clerkship

What was your first clinical clerkship rotation?

Oddly, I started my third year with a sub-internship rotation on the Burn/Plastics service as my first rotation. Not sure how that happened... I managed my own patients like a 4th year student, did lots of wound care, and even got to harvest a few skin grafts. It was trial by fire.

In a recent JAMA article, 3rd year medical students who started their clinical experiences in an Internal Medicine rotation overall did better on overall clerkship grades, when compared those who started their rotations on the Ob/Gyn, Psychiatry, or Family Medicine service.

These 3rd year medical students were spread across four distinct sites at the University of Illinois (Chicago, Peoria, Rockford, Urbana). An analysis of covariance was used to test for differences between groups. In this case, differences in the first clerkship rotation were compared with respect to:

• NBME shelf exam scores (score range 0-100)
• Student clinical performance ratings (score range 12-30)
• Overall 3rd year clerkship grades (score range 12-30)
• USMLE Step 2 exam scores

Results

Interestingly, students who began their 3rd year clerkships with Internal Medicine fared better on the NBME exams (p<0.001) and clerkship grades (p=0.02) during their entire 3rd year.

Specifically, they performed better than students who began their rotations with such specialties, such as Ob/Gyn, Psychiatry, and Family Medicine. Clinical performance ratings and USMLE Step 2 scores, however, were not associated with the the student's first clinical clerkship. 

It seems that the Internal Medicine rotation provides a crucial foundation in preparing for other clerkships. It is the best first clerkship for students just starting their clinical rotations.

Hmm, I wonder...
There has been a lot of talk about significantly reorganizing in the U.S. medical school curriculum. Much hype has focused on incorporating more clinical experiences as early as the 1st year of medical school. This study seems to suggest that students should all start with Internal Medicine as their first clinical experience. This, however, is logistically impossible because of limited space on the Internal Medicine teams.

This begs the question - Why DO students have to start medical school at the same time each year? Why can't medical schools enroll students on a rolling basis, such as on the 1st day of each month? This would allow a more equivalent clinical clerkship experience, because students can now follow the same sequence of clerkships. Everyone could start with Internal Medicine.

Reference
Kies SM, Roth V, & Rowland M (2010). Association of third-year medical students' first clerkship with overall clerkship performance and examination scores. JAMA : the journal of the American Medical Association, 304 (11), 1220-6 PMID: 20841536

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Article Review: Student documentation in the chart

Do you have medical students rotating in your Emergency Department? Are they allowed to document in the medical record?

Charting in the medical record is the cornerstone of clinical communication. You document your findings, your clinical reasoning, and management plan. The medical record allows communication amongst providers. Chart documentation is a crucial skill that every medical student should know, as stated by the Association of American Medical Colleges (AAMC).

However, there is a growing trend whereby medical students are no longer being allowed to document in the medical record. I find this alarming, because this was often how I assessed their knowledge and clinical competency. Various reasons for excluding students include:

• Medicolegal risk
• Inaccurate information
• Unsigned notes
• Inability to bill and be reimbursed

This is especially true for institutions where the medical record is electronic and not paper-based. These electronic medical records (EMR) tend to lock-out and restrict access by students.

This Academic Medicine study reports results from a 23-item survey of medical school deans in the U.S. and Canada. The response rate was 63% (79/126).

• 96% and 94% of respondents stated that 4th-year student notes should be included in the inpatient and outpatient records, respectively.

The respondents felt that a student's inability to document in the chart would have negative consequences:

• Not feeling a part of the team (96%)
• Inadequate preparation for internship (95%)
• Lack of a sense of being involved (94%)

Bottom line - Getting to the point:

Medical school deans overwhelmingly support that medical students' notes be included as part of the patient's official medical chart from an educational standpoint. Furthermore, it promotes a sense of inclusion on the medical team.

The authors advocate that governing organizations such as AAMC, the Liaison Committee for Medical Education (LCME), or the Alliance of Clinical Educators (ACE) should officially recommend that student notes be included in the patient chart.

I totally agree. It isn't like entering PGY-1 residents can magically document better now that they have just graduated from medical school. Medical students should be taught how to and be allowed to document in the chart, with appropriate guidance. The starting PGY-1 residents are already stressed out in adapting to a new system with new responsibilities. There's no need to add chart documentation to their list of things to learn!

Reference
Friedman E, Sainte M, & Fallar R (2010). Taking note of the perceived value and impact of medical student chart documentation on education and patient care. Academic medicine : journal of the Association of American Medical Colleges, 85 (9), 1440-4 PMID: 20736671

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Article Review: Expectations of medical student clinical skill

Traditionally in U.S. medical schools, the first 2 years focus on book-learning and the last 2 years focus on clinical experience. This follows the Flexner model of medical training.

A growing trend in U.S. medical schools is the early integration of clinical experience into the first 2 years of medical school. Successful longitudinal integration depends on setting clear goals for basic clinical skills competency. Not much is known about what basic clinical skills medical students should have upon entering their traditional clinical clerkship rotations.

This survey-based study from the University of Washington assessed 3 populations:

1. Third-year medical students, who have completed 3 months of clerkships
2. Preclinical faculty who provide second-year medical students early clinical teaching and exposure
3. Clerkship directors of required 6 clerkships (IM, FM, Surgery, Psych, Peds, Ob/Gyn)

Response rates ranged from average to excellent. Generally a survey response of >70% is reasonable.

• Students: 62% (115 of 185)
• Preclinical faculty: 91% (30 of 33)
• Clerkship directors: 58% (56 of 97)

Outcome Measures

Skills assessed were divided into 3 categories. Each subject was asked to rank what level of preparation was expected for 3rd year students beginning their clinical clerkship. The rating scale ranged from 1 to 5 (1=none, 5= considerable preparation).

1. Basic Clinical Skills

• Communication skill
• Taking a comprehensive history
• Complete review of systems
• Performing a full physical exam
• Comprehensive oral case presentation
• Complete write-up
• Working as a team member
• Receiving feedback

2. Advanced Clinical Skills

• Focused history
• Focused physical exam
• Focused oral presentation
• Preparing SOAP notes
• Clinical reasoning
• Preparing assessment and plan
• Differential diagnosis

3. Knowledge-Related

• Basic science knowledge

Results

There were some interesting statistically-significant findings.

• Preclinical faculty and students had higher expectations than clerkship directors when it came to most basic clinical skills preparation.
• Students, as a whole, expected greater preparation for all of the 7 advanced clinical skills prior to starting clerkships.
• Interestingly, clerkship directors had higher expectations for only 1 item when compared to preclinical faculty. That was in "preparing SOAP notes". I totally agree. Clinical students notoriously do not appreciate the importance of documentation.

Bottom Line

In the upcoming age of vertical integration of clinical experiences throughout medical school, there should be more open communications about expectations of the 3rd year clerkship student. This is similar to the concept of handing off patients from one provider to another for further care. In this case, preclinical faculty are "handing off" students to clerkship directors for further education. We need to make sure that both parties are on the same page.

Reference

Marjorie Wenrich1, Molly B. Jackson, Albert J. Scherpbier, Ineke H. Wolfhagen, Paul G. Ramsey, & Erika A. Goldstein (2010). Ready or not? Expectations of faculty and medical students for clinical skills preparation for clerkships Medical Education Online, 15 : 10.3402/meo.v15i0.5295

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Article Review: Evaluating students using RIME method

How do evaluate medical students and residents, who are rotating through your Emergency Department? Do you have a structured framework for assessing their competencies?

Have you heard of the RIME method of evaluating learners on their clinical rotation? Dr. Lou Pangaro (Vice Chair for Educational Programs in the Dept of Medicine at the Uniformed Services University) published a landmark article in 1999 on his simple yet effective approach in evaluating medical students and residents. I had the pleasure of briefly meeting Dr. Pangaro when he gave CDEM's keynote speech in 2008.

As faculty evaluating students, we are constantly inundated with various evaluation forms and complex assessment tools. To optimize inter-rater reliability amongst evaluators, the key is to keep the evaluation simple, short, and concrete. In short - KISS - Keep It Simple Stupid.

RIME sets itself apart from other evaluation tools by standardizing the vocabulary so that we are talking about the same thing. It proposes a developmental model for novice through advanced learners. It represents a system which assesses the learner's skills, knowledge, and attitudes, based on observed behavior.

In a nutshell, a medical student's performance is classified into one of 4 categories:

1. Reporter

• Reliability gathers accurate history and performs physical examination
• Has basic medical knowledge
• Adequately communicates findings
• Average interpersonal skills with patients

2. Interpreter

• Able to prioritize problem list based on patient complaint
• Generates differential diagnosis list
• Interprets data (labs, EKG, imaging) to adjust differential diagnosis list
• Engages more as active provider for patient

3. Manager

• Tailors plan to patient's circumstance and presentation
• Demonstrates high-level interpersonal skills
• Starts to educate patients about disease process and clinical course
• Demonstrates more medical knowledge and advanced judgment in patient management plan
• Proposes reasonable treatment plans while incorporating patient preferences
• More adept at procedural skills

4. Educator

• Performs at high-level in managing multiple patients
• Practices self-directed learning
• Able to share knowledge with others (junior residents and medical students)
• Supervises junior trainees
• Knowledgeable of current medical evidence

Personally, I believe that the RIME structure should correlate with particular training levels as follows:

• Reporter - goal for medical student in first clinical year
• Interpreter - goal for medical student in final clinical year and for PGY-1 resident
• Manager - goal for PGY-2 resident
• Educator - goal for PGY-3+ resident

The RIME method of evaluation demonstrated high reliability and validity when implemented in an internal medical clerkship.

Reference
Pangaro, L. (1999). A new vocabulary and other innovations for improving descriptive in-training evaluations Academic Medicine, 74 (11), 1203-7 DOI: 10.1097/00001888-199911000-00012

Article Review: Revised EM Clerkship Curriculum

Last year, I was fortunate to be involved in a 1-year consensus group building exercise in revising the 2006 EM Clerkship Curriculum. Led by my friend Dr. David Manthey (Wake Forest), members of the Clerkship Directors in Emergency Medicine (CDEM) debated and went through seemingly an infinite number of drafts of the updated curriculum.

The final manuscript was just published in Academic Emergency Medicine this month.

What we came up with was the 2010 EM Clerkship Syllabus. Four goals were addressed:

1. Refining the objectives based on the ACGME core competencies
2. Restructuring and refining the knowledge content
3. Writing objectives for the procedures syllabus
4. Identifying areas of the LCME guidelines which are addressed by the syllabus

What I'd like to highlight is #2:

Restructuring the EM clerkship's knowledge content

A major goal of the revised curriculum was to allow for an EM clerkship director to more easily cover the core content material of EM within a 4-week period. This was difficult to accomplish with the overly comprehensive original curriculum from 2006.

Basically, knowledge content was categorized into three areas:

1. Fundamental set of emergent patient presentations
2. Set of specific disease entities, unique to EM
3. Procedural skills

Emergent Patient Presentations

We eliminated redundant topics and content that would likely be covered in other core clerkship rotations. This resulted in 10 emergent patient presentations that all EM students should be familiar with:

• Abdominal pain
• Altered mental status
• Cardiac arrest
• Chest pain
• Gastrointestinal bleeding
• Headache
• Poisoning
• Respiratory distress
• Shock
• Trauma

Specific disease entities include:

1. Cardiovascular

• Abdominal aortic aneurysm
• Acute coronary syndrome
• Acute heart failure
• Aortic dissection
• DVT / pulmonary embolism

2. Endocrine / Electrolyte

• Hyperglycemia
• Hyperkalemia
• Hypoglycemia
• Thyroid storm

3. Environmental

• Burns / smoke inhalation
• Envenomation
• Heat illness
• Hypothermia
• Near drowning

4. Gastrointestinal

• Appendicitis
• Biliary disease
• Bowel obstruction
• Massive GI bleed
• Mesenteric ischemia
• Perforated viscous

5. Genito-urinary

• Ectopic pregnancy
• PID / TOA
• Testicular / ovarian torsion

6. Neurologic

• Acute stroke
• Intracranial hemorrhage
• Meningitis
• Status epilepticus

7. Pulmonary

• Asthma
• COPD
• Pneumonia
• Pneumothorax

8. Psychiatric

• Agitated patient
• Suicidal thought/ideation

9. Sepsis

Basic Understanding of Procedural Skills

Note that for basic procedures, students need to demonstrate basic skill competency. For more advanced skills (joint relocation, endotracheal intubation, FAST ultrasonography in trauma), students need to demonstrate a basic understanding of the skill.

• Peripheral Access
• Airway Management
• Arrhythmia Management
• NG tube placement
• Foley catheterization
• Dislocations and Splinting
• Incision and Drainage
• Trauma Management
• Wound Care

For more specifics, download the article and the 3 online supplements which detail the entire EM clerkship curriculum.

Hot off the press

Preliminary online "chapters" of the emergent patient presentations and specific disease entities, which follow this 2010 EM clerkship syllabus template, can be found on CDEM's curriculum website: www.cdemcurriculum.org. This site may become the free, go-to online textbook for EM clerkship students. This site will also eventually host my online DIEM (Digital Instruction in Emergency Medicine) cases, which were indirectly referenced in this article as adjunctive "online interactive learning modules".

Reference

Manthey, D., Ander, D., Gordon, D., Morrissey, T., Sherman, S., Smith, M., Rimple, D., Thibodeau, L., & , . (2010). Emergency Medicine Clerkship Curriculum: An Update and Revision Academic Emergency Medicine, 17 (6), 638-643 DOI: 10.1111/j.1553-2712.2010.00750.x

Handouts from CORD 2009 Academic Assembly

For those of you who weren't able to make it to the high-yield 2009 CORD Academic Assembly in Orlando a few months ago, the handouts are now available for download on the CORD website. If you are an educator in EM, these are fantastic resources. Handouts are available from each track:

• Best Practices
• Clerkship Directors in Emergency Medicine (CDEM)
• Emergency Medicine Association of Research Coordinators (EMARC)
• Medical Education Research Certification (MERC)
• Navigating the Academic Waters
• New Program Directors
• ... and many others

Enjoy!

Article review: Preparing for clinical clerkships during medical school

Do you remember the sheer terror you felt, when you first started your medical school clinical rotations? Your first two years were probably spent in classrooms and small-group labs discussing anatomy, pharmacology, pathology, etc.

Then BAM! You are thrown into the deep end of the pool. You are now on a clinical team of medical professionals taking care of actual patients!

Some students fare better than others during this abrupt transition period. This commentary in Academic Medicine provides a framework to help students adapt to this change, by understanding adult learning literature. Specifically, the authors review the concept of Kolb's learning cycle.

Kolb initially proposed that learning occurs in a 4-stage cycle. This consists of:

1. Concrete Experience (experiencing an event)
   
2. Reflective Observation (reflection on that concrete experience)
   
3. Abstract Conceptualization (generation of new approach or style based on reflection)
4. Active Experimentation (test the new approach or style in reality)
   

The authors of this article propose a 5-stage modified Kolb cycle to adapt to the new challenges of the clinical years of medical school:

1. Prepare for the clinical setting
2. Experience the clinical setting
3. Reflect on the experience
4. Conceptualize new approaches
5. Testing new approaches

1. Preparing for the Clinical Setting

• As a student, identify what your roles and responsibilities are on the team. The clerkship director should tell you this, but if not, seek out the answer. What should your presentations be like for new and established patients? Do you write notes in the chart, and if so, what is the format preferred?
• Remember to do no harm. As a student, be sure not to give definitive answers to patients or families if you are not sure of the answers. Tell them that you will find out the answer. Also, do not perform procedures with which you are unfamiliar. Let the resident or attending know that you are uncomfortable with the new procedure and would like to observe at this time.
  

2. Experiencing the Clinical Setting

• Keep a log of patient encounters, framed within goals and objectives in the medical school curriculum. Such objectives might include: communication with a consultant, dealing with a difficult patient, practicing cost-effective medicine when deciding on prescribing discharge medications.
• Learning should be driven by the student. Read more about conditions or symptoms from your patient encounters. For me personally, I retain information more when it's contextually based.
• Share what you have learned by teaching your fellow team members. Teaching reinforces what you've learned.
• Move beyond "reporter" status. Medical students are traditionally perceived as data gatherers. Go one step further and think about a broad differential diagnosis list, based on your gathered data, without prompting from your resident or attending.
  
• Build collaborative relationships with your team members. In team-based clinical work, it is crucial to understand the importance of collaboration. Unit secretaries, mid-level providers, nurses, and other professionals in the health care system are all part of the greater team.
• Set a high professionalism standard. Sometimes students may witness unprofessional behavior. Think about how you would have handled the scenario differently, so that you don't fall into that trap in the future. Emulate those who exhibit humanistic behavior towards their patients and colleagues.
• Develop habits that promote mental health and physical and social well-being.

3. Reflecting on Experience

• A critical component in the "learning cycle" is the reflective piece. For self-reflection to improve your learning, seek out frequent feedback on how you are performing from residents and faculty. Be specific in what you are seeking feedback on -- "Can you tell me how I did in taking this patient's history?" or "Any feedback about my venipuncture procedure?"
• During your reflection of your clerkship experiences, think about what you like and don't like about that specialty. Start developing a pros/cons list of factors which will play into your decision-making about selecting a career choice. Clearly, the specialty of Emergency Medicine is the best, but I suppose I'll let you come to that decision yourself.

4 and 5. Conceptualizing and Testing New Approaches

• Based on self-reflection, think of how you might improve upon yourself or what you are doing. This might be how you approach a difficult patient, how you ask sensitive questions, troubleshooting a procedure, or present your differential diagnosis list.
  
• Test your new approaches.
• Repeat as new experiences arise.
  

Reference
Greenberg L, & Blatt B (2010). Perspective: successfully negotiating the clerkship years of medical school: a guide for medical students, implications for residents and faculty. Academic medicine : journal of the Association of American Medical Colleges, 85 (4), 706-9 PMID: 20354392

Poll: Evaluation anonymity

As educators, we are constantly being asked to complete evaluation forms for medical students and residents. Most are in the form of formative evaluations. That means that you are giving the learner frequent feedback (like a coach) so that they can do better in the immediate future. This is in contrast to summative evaluations, which are conducted for the purposes of "grading" the learner.

More and more institutions are moving towards a daily post-shift evaluation of medical students and residents rotating in the Emergency Department. This is often done online. There are pros and cons for having the evaluations be anonymous.

PROS (for anonymity)

• Faculty may avoid giving negative feedback to learners for fear of awkward interactions on future ED shifts.With anonymous evaluations, faculty may feel more comfortable giving constructive criticism.
  

• If faculty avoid giving constructive criticisms (or at least very watered down) in non-anonymous evaluations, problem issues may go undetected longer because no one comments on them.

CONS (against anonymity)

• Medical trainees are adult learners and should be adult enough to hear direct feedback.
• Knowing who the evaluation is from allows for more direct discussion of specific cases or scenarios.

What do you think should be done?

Comments are welcome to explain your reasoning from the perspective of a learner or educator.

Article review: SAEM Tests

This is is a great look back at how SAEM Tests were developed and now used by EM clerkships across the country. Because EM does not have a National Board of Medical Examiners shelf exam, a tremendous effort was made by the authors to create a set of validated questions for clerkship directors to use.

Specifically point serial correlation coefficients (range -1 to +1) were calculated for each question. A high coefficient means a high correlation between the performance on the individual test question and the performance on the overall test. After rewriting 25% of the test questions because of poor correlation coefficients, all current test questions now have a point serial correlation coefficient >0.2.

SAEM Tests (www.saemtests.org)

• Started in June 2005
• 24 individual tests covering a spectrum of topics
• 565 test questions

Currently the tests are used mostly for formative (self-learning) purposes, but the hope is that there can be a standardized, summative "shelf-like" test for clerkships. There is currently a pilot "proctored" test, which is comprised of the most validated test questions.

Sorry for the delay in posting this review (watching closing ceremonies of Olympics)! Check out this article to see how tests are built and validated.


Reference
Senecal EL, Thomas SH. Beeson MS. A Four-Year Perspective of Society for Academic Emergency Medicine Tests: An Online Testing Tool for Medical Students. Acad Emerg Med 2009; 16:S42–S45.

Hot off the press: Review of "EM Clerkship Primer" book

In an upcoming issue of the Academic Emergency Medicine journal, there is a glowing review of a collaborative project that I was involved in. If you are a medical student about to do an EM rotation, or serve as a faculty advisor for an EM medical student, feel free to distribute this EM Clerkship Primer (FREE book!) for them to read. This was the first official project to come out of the Clerkship Directors in Emergency Medicine (CDEM). It was written by 22 established medical educators in EM, led by our fearless leader/ editor-in-chief, Dave Wald. Go, Dave!


EMERGENCY MEDICINE CLERKSHIP PRIMER: A MANUAL FOR MEDICAL STUDENTS. Edited by David A. Wald, DO. Free for students and educators; 108 pp; download PDF at http://www.saem. org/CDEM (look under "Resources for Medical Students").

The Emergency Medicine Clerkship Primer is a unique and authoritative introduction for medical students entering the specialty of emergency medicine (EM). It has been prepared by physicians who are nationally recognized for their dedication to medical student education. The guide provides a thorough, yet succinct, primer that introduces the steps to not only have a successful clerkship, but also to understand issues central to the practice of EM.

The primer has 24 chapters, including introductions to EM and the clerkship, unique aspects of EM and ED workups, complaint-directed history taking, formulation of differential diagnoses, enhancing oral case presentation skills, diagnostic testing, whether obtaining a diagnosis is important, and appropriate disposition and discharge instructions. There are also helpful chapters on topics such as ED documentation pearls, interacting with consultants, meeting patient expectations, and procedural skills.

This primer has been prepared for all medical students rotating in EM, regardless of their chosen specialty. It begins by providing some background into EM and then transitions into how to perform well in an EM clerkship. The medical student, by reading these well-organized and concise chapters, will develop an understanding of the skill set that is utilized by emergency physicians. In addition, the medical student will learn that the presentation and assessment of an undif- ferentiated patient in the ED is distinct from that of the patient with a known diagnosis in the inpatient ward.

For the medical student planning a career in EM, the Emergency Medicine Clerkship Primer provides a single, inclusive resource that contains references for articles that are essential to emergency physicians. It also provides insight into the background of EM residency education via a review of the core competencies required for residency training.

Overall, the Emergency Medicine Clerkship Primer is an exceptional guide for medical students. Its concise style and valuable content make it a distinctive and irreplaceable resource. Reading it is a highly recommended first step for a successful entrance into a career in EM.

Kapil Dhingra, MD, MBA
Erik Laurin, MD (eglaurin@ucdavis.edu)
University of California, Davis Medical Center
Sacramento, CA

Free EM clerkship primer for medical students

Emergency Medicine as a specialty approaches patients in a slightly different way from other specialties. We first look to rule-out emergent, life-threatening causes of each patient's presentation. Is the headache a subarachnoid hemorrhage? Is the shortness of breath from a pulmonary embolism? Emergency physicians need to be especially skilled in a broad range of clinical knowledge in addition to multitasking, communicating to patients and consultants concisely, and overall efficiency.

So why hasn't there been a specific reference book addressing the unique aspects of EM for the medical student? It seems a bit unfair to ask the medical student, who is new to the Emergency Department setting, to acclimate to the chaotic environment and not get lost in the shuffle.

Thus about a year ago, the Clerkship Directors in Emergency Medicine (CDEM) group put together an EM Clerkship Primer to address these very issues. We wrote a reference manual called "Emergency Medicine Clerkship Primer: A Manual for Medical Students", which is available for free. The project editor was Dr. Dave Wald (Temple), and I was fortunate to be one of the Associate Editors. There are lots of notable contributing authors.

The chapters include:

1. Intro to the specialty of EM
2. Intro to the EM clerkship
3. EM clerkship goals and objectives
4. Unique educational aspects of EM
5. Differences between the ED, the office, and the inpatient setting
6. Undifferentiated and differentiated patients
7. Performing a complaint-directed history and physical exam
8. Data gathering skills
9. Developing a case-specific differential diagnosis
10. Diagnostic testing in the ED
11. Developing a plan of action
12. Diagnosis: Is it possible? Is it necessary?
13. Disposition of the ED patient
14. Discharge instructions
15. Documentation
16. Enhancing your oral case presentation skills
17. Interacting with consultants and primary care physicians
18. Patient satisfaction - meeting patients' expectations
19. Providing anticipatory guidance
20. Procedural skills
21. Suggested reading and other educational resources for med students
22. How to get the most out of your EM clerkship
    

If you are a medical student interested in EM or a faculty advisor, you should download and read this FREE resource. Yes, I said it's free. We received a generous donation from the University of Rochester to hire a copy-editor.

Link: http://www.saem.org/saemdnn/Portals/0/NTForums_Attach/ED%20Primer.pdf

Article review: Standardizing the EM clerkship patient encounter experience

As a medical student, do you remember your EM clerkship experience and whether you saw a wide variety of patient chief complaints? Did your fellow medical student on the EM clerkship rotation, who was going into Orthopedics, seem to only see patients with orthopedic complaints?


In a study in Academic EM in 2008 at Harbor-UCLA Medical Center, medical students were provided a list of 10 chief complaints which they had to see during their 4-week rotation. These chief complaints were:

1. Abdominal pain
2. Acute coronary syndrome
3. Asthma
4. Diabetic ketoacidosis / hyperglycemia
5. Headache
6. Laceration
7. Orthopedic injury
8. Pediatric fever
9. Traumatic injury
10. Vaginal bleeding

When I last spoke with Dr. Wendy Coates (one of the authors), this study arose because she found that medical students, if left on their own, will NOT see a variety of patients during the EM clerkship rotation.

This was a prospective, non-randomized, case-control study. The control group (n=18) included students who saw whichever patients they desired during the EM clerkship rotation. The test group (n=24) included students who were assigned to see each of the 10 listed chief complaints during rotation.

Results: Using a difference in means analysis, the test group students showed greater exam score improvement (post-test score minus pre-test score), compared to the control students. What was interesting was this exam tested a broad range of topics including and beyond the 10 assigned chief complaints.


Some ideas
After reading this article, I find myself thinking about whether a similar approach might be applied in other settings.

1. I think this would be terrific idea for interns (PGY-1 residents) on the EM rotation. Many interns from a variety of departments rotate through the Emergency Department to gain a broad experience in managing acute medical conditions. Although I find that most interns are open to seeing a variety of chief complaints, several naturally gravitate towards only seeing patients with complaints which are directly relevant to their specialty. This checklist of chief complaints would encourage interns to gain a more balanced and broad EM knowledge base.
2. Another idea -- there could be a completely different checklist of chief complaints for students who are rotating on their second EM rotation. These chief complaints could include more advanced topics such as: eye complaint, acute back pain, drug of abuse, and seizure/stroke.

Do you have any ideas or thoughts?

Reference:
Lampe CJ, Coates WC, Gill AM. Emergency medicine subinternship: does a standard clinical experience improve performance outcomes? Acad Emerg Med. 2008 Jan;15(1):82-5.