Evolution of emergency medicine teaching for medical students
Antonio Celenza, MB BS, MClinEd, FACEM, FCEM, Associate Professor.
See also pp. 276–281
Professor MacFarlane’s description of the implementation of emergency medicine (EM) teaching in South Africa draws parallels with similar curriculum-change processes that have occurred in Australasian medical schools over the past decade or so. In particular, the fortuitous timing of curriculum review and formation of an academic unit of EM at the University of Western Australia (UWA) in 1997 eventually resulted in a 4 week stand-alone term in EM.1,2 These factors have also led to the creation of the integrated Acute and Perioperative Care block in South Africa.1 Introducing new specialties into a curriculum might appear revolutionary for many of the traditional academic disciplines, but there are sound and evolving reasons for teaching medical students in the ED.
Most medical students will spend some of their prevocational work time in the ED. Prior exposure to EM eases the transition process from student to doctor in these stressful environments and subsequently gives a basis for acute management in other disciplines. Interns might be required to manage ward emergencies from their first day at work. Emergencies occur in every discipline, at any time, in or out of health-care settings and doctors might be asked to assist during these episodes. Undergraduate EM teaching can commence the learning of these skills, such that all medical practitioners have the capacity to deal with these eventualities.
Perhaps more importantly, the ED also provides opportunity for students to practise generic history-taking and communication skills, physical examination, procedural skills, clinical reasoning and documentation on a large number and wide variety of patients. Traditional ward-based teaching of these skills is becoming more and more difficult or limited because of fundamental changes in hospital function. These include:
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Attempts to increase hospital efficiency have led to same-day and day-case admissions, restriction of non-emergent admissions and the increased use of ambulatory care. All of these factors restrict the number of suitable patients for student learning in inpatient hospital wards.
- 2
The undifferentiated patient now often has the majority of diagnostic and therapeutic interventions performed in the ED prior to acceptance by inpatient units, as a result of increased subspecialization and role delineation within some hospitals. The ED is the environment where the bulk of these cases are initially assessed, diagnosed and treated, and therefore where medical students might attempt to learn acute management.
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Access block necessitates that ED staff now not only commence the initial assessment, investigation, treatment and clinical decision-making, but also maintain patient management for hours or days.
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More intensive inpatient investigation, higher use of inpatient allied health treatments and shorter inpatient lengths of stay also limit the number of patients that are available for students to see. In a recent survey of a group of New South Wales’ hospitals, only 49% of all ward patients were accessible to medical students, as 25% were unfit to be seen, 11% were absent and 15% were inaccessible for other reasons.3 Some entire wards were deemed to be off limits to students! Comparable ED figures are unknown, but student access to ED patients might be significantly better than for ward patients because of the large throughput of patients, and patients waiting to be seen by a doctor, or for investigation results, or for inpatient beds.
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Shifting of work and patients to private hospital practice might diminish the teaching capacity of some disciplines in public hospitals, unless private hospitals also regularly begin to teach.
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ED observation wards now frequently function as short-stay units and admit a casemix no longer seen on a traditional ward. These observation wards manage toxicological patients, social and psychiatric admissions, clinical decision pathway patients (e.g. with chest pain) and patients with minor illness such as asthma or cellulitis destined to go home, or minor injuries. Observation wards might be the only opportunity for students to see these types of patients.
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In addition, some ED and observation units have instituted discharge coordinators, social workers, alcohol and drug liaison nurses, falls assessment teams and psychiatry liaison nurses. This allows students to be involved with discharge planning, whose lack is a potential criticism of EM teaching. Experience in this is now becoming available to medical students in these units.
Nearly 10 years after EM teaching was first touted as being suitable as an integral, but independent part of the undergraduate curriculum, UWA has now reviewed the clinical curriculum, with a focus on EM. The perceived educational benefits of EM teaching, and persistent positive evaluations led to an unprecedented student petition being presented to the Faculty of Medicine to request an increase in curriculum time for EM. The Medical Faculty reviewed the clinical curriculum in view of this, and increasing student numbers, which led to a proposal for EM clinical clerkship to increase to 5 weeks together with additional weeks for EM large-group teaching in 2007. The learning outcomes will be similar to the current programme, including principles of EM and prehospital care, dealing with undifferentiated presentations, minor and major injuries, critical illness and resuscitation, toxicology and environmental medicine, and related clinical and procedural skills. In separate parts of the curriculum, EM academics teach elements of physiology, pharmacology, evidence-based medicine, core clinical and procedural skills, supervise scientific projects and assist in ongoing curriculum development.
Although similarities exist, the Witwatersrand curriculum in comparison integrates aspects of anaesthetics and forensic medicine with EM and trauma, which are taught separately at UWA. The integration of these components, progression of learning, use of a variety of teaching methods and the requirement for formal assessment of EM is highly praiseworthy and a potential model for other South African medical schools. It appears that the trauma and anaesthetic components dominate the 6 week block, likely because of the prevalent patient casemix in South Africa. The total clinical experience in the ED seems a little limited despite the broad and intense formal teaching. However, the reassessment of the Witwatersrand curriculum and formal allocation of time for EM teaching is an excellent start and, in time, must evolve to take full advantage of the potential educational benefits of all of EM.
Importantly, medical schools need to continually evaluate each discipline’s teaching and reward those with positive student feedback on learning opportunities by expanding their curriculum time and academic resources. This might be at the expense of other disciplines that no longer provide excellence in teaching, because of changes in work practice or because of the lack of availability of clinical teachers. Academic leaders in EM both in South Africa and Australasia need to champion this process. The EM revolution is over, get ready for its evolution!
Competing interests
Antonio Celenza is Section Editor – Education and Training for Emergency Medicine Australasia.
