Transcript Document

How to Run an
Emergency Medicine
Residency Program
Jim Holliman, M.D., F.A.C.E.P.
Professor of Military and Emergency Medicine
Uniformed Services University
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, Maryland, U.S.A.
My Background for This
Lecture
• Program Director for proposed Penn State
University E.M. Residency and wrote the
Program Information Form for this in 1991
• Helped develop Joint E.M. Residency Program
(York Hospital – Penn State Hershey) and
served as Associate Director of this 1994 –
2003
• Associate Director of the independent Penn
State Hershey E.M. Program 2004 – 2007
• C.O.R.D. member 1994 - 2007
General Benefits of Having Specialty
Residency Training in Emergency
Medicine (E.M.)
Provides core of specialists to staff
emergency departments (E.D.'s).
Provides physician leadership :
–E.D. administrators or managers
–Prehospital care system directors
–Coordinate outpatient & inpatient care
Ensures quality, depth, and uniformity of
training for emergency care.
Teaching E.M. residents can provide a lot
of career satisfaction, and can be fun !
Essential Ingredients for a Successful
E.M. Residency Program
.
• An enthusiastic, energetic, career-dedicated,
knowledgeable, and clinically competent
Program Director
• A cooperative and supportive Department
Director and Core Faculty
• An energetic and supportive Program
Coordinator
• Support from the hospital administrators and
other clinical departments
Start-Up Sequence for a New
E.M. Residency Program
• Obtain institutional support and initial financing.
• Find and hire an experienced Program Director.
• Put in place all the structural components (see the
Accreditation Council for Graduate Medical
Education web site www.acgme.org for the “Common
Program Requirements” and the Residency Review
Committee for E.M. Specific Program Requirements).
• Fill out and submit the Program Information Form
(PIF) to the ACGME.
• Be nice to the Residency Review Committee
representatives when they arrive to inspect the
proposed program.
Sample Text Lifted from the ACGME Web
Site Document “Common Program
Requirements” (an 81 page document)
.
1.
There must be a single program director with authority and accountability for the
operation of the program. The sponsoring institution’s GMEC must approve a
change in program director. After approval, the program director must submit this
change to the ACGME via the ADS.
[As further specified by the Review Committee]
2. The program director should continue in his or her position for a length of time
adequate to maintain continuity of leadership and program stability.
3. Qualifications of the program director must include:
a) requisite specialty expertise and documented educational and administrative
experience acceptable to the Review Committee;
b) current certification in the specialty by the American Board of ________, or
specialty qualifications that are judged to be acceptable by the Review
Committee; and,
c) current medical licensure and appropriate medical staff appointment.
[As further specified by the Review Committee]
4. The program director must administer and maintain an educational environment
conducive to educating the residents in each of the ACGME competency areas. The
program director must:
a) oversee and ensure the quality of didactic and clinical education in all
institutions that participate in the program;
b) approve a local director at each participating institution who is accountable
for resident education;
c) approve the selection of program faculty as appropriate;
d) evaluate program faculty and approve the continued participation of program
faculty based on evaluation;
e) monitor resident supervision at all participating institutions;
f) prepare and submit all information required and requested by the ACGME,
Assistive Resources in
Starting a New E.M. Residency
• The Society for Academic E.M. (S.A.E.M.) has a
Residency Consultation Service (for a fee the Service
will send an experienced reviewer to analyze the
proposed program and its PIF).
• The Council of Residency Directors (C.O.R.D.) has
helpful information on its web site
(www.cordem.org) and at its several meetings each
year (the Program Director(s) should be a member).
• S.A.E.M. (www.saem.org) and A.C.E.P.
(www.acep.org) and E.M.R.A. (www.emra.org) also
have good reference information.
General E.M. Residency
Program Requirements
• Program must be at least 36 months in duration
(can be PGY 1,2,3 or PGY 2,3,4 or PGY 1,2,3,4
formats).
• Should teach the skills, knowledge, and
behaviors of E.M. practice.
• At residency completion, graduates should be
able to practice E.M., add new skills and
knowledge, and monitor their own well being.
Faculty Requirements for U.S. E.M.
Residency Programs
Department chief must have :
–E.M. board certification, administrative & clinical E.M.
experience, academic achievement, involvement in medical
organizations, same authority as other institutional chiefs.
Program Director must have :
–E.M. board certification, > 3 years experience, be clinically
active, be scholarly active, and have at least 50 % “protected
time” to run the residency, & full authority over the program.
Teaching Faculty must have :
–At least one per every 3 residents, 25 % of time protected for
academic activities, some must do research, most must be
E.M. board certified, must provide 24 hour a day E.D.
coverage, and there must be a faculty development
program.
Facility Requirements for U.S. E.M.
Residency Programs
Patient census > 30,000 (total) per year.
Pediatric census 15 % or 4 months full time equivalent.
Critically ill / injured patients : at least 3 % of census or > 1000
per year.
At least 2000 patient encounters per resident per year.
Accredited medicine & surgery residencies must be at same
clinical site.
Must have offices and program support space for faculty &
residents.
Stat lab results should be available in < 1 hour.
Must have at least 5 hours per week didactic instruction by
faculty.
Requirements for E.M. Residency
Sponsoring Institutions
• Medical school affiliation desirable
• Sponsors must be committed to
graduate medical education
• Long term financial commitment to the
program is needed
• Affiliation agreement needed for each
hospital where residents rotate
Additional E.M. Residency Sponsoring
Institutions Requirements
• One hospital must be primary ; the
Program Director must be based here.
• Reasons to include multiple hospitals
should be clear.
• Multiple hospitals should not be
geographically distant.
• Residents must participate in
conferences even when at different
hospitals.
• One faculty must be responsible for
resident activities in each institution.
Requirements for Residents in
U.S. E.M. Training Programs
May not work > 12 hours continuously in E.D.
May not have more than 60 hours per week total clinical time
May not work > 72 hours per week including on-call & conferences
Must have at least one day off in every 7 days
Must be relieved of clinical duties sufficient to attend at least 70 %
of scheduled conferences
 > 50 % of rotations & clinical time must be in E.D.
Must keep a procedure logbook
Must have followup information on admitted patients
May not be supervised by resident physicians from specialties
other than E.M. when in the E.D.
General Structure of U.S. E.M.
Residency Programs (cont.)
> 50 % of time (> 18 months) in program must
be in the E.D.
Important "off-service" rotations :
–Critical care units (pediatric, medical, surgical) : at
least two months required
–Trauma surgery
–Pediatrics
–Orthopedics
–Anesthesia
–Medicine / cardiology
Non-E.D. E.M. Rotations Usually
Included in E.M. Residency Programs
Toxicology
Pre-hospital care
Aeromedical care (flying usually optional
for residents)
Research
1 to 2 months of electives
E.M. Residency Program
Director Responsibilities
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Develop goals of program in writing
Select new residents
Participate in faculty evaluation
Ensure appropriate resident supervision
Regularly evaluate the residents in writing
Handle resident grievances
Manage resident stress and wellness
Make sure the program continues to meet the
ACGME RRC-EM requirements
E.M. Residency Educational
Program Requirements
• Conferences for residents
– At least 5 hours weekly of planned
conference developed by the EM program
– Should include : curriculum, Morbidity and
Mortality, journal review, administrative
seminars, and research methods
– Faculty should attend conferences also
E.M. Residency Educational
Program Requirements (cont.)
• Research and scholarly activity
– Journal clubs and research conferences
– Professional and scientific meetings
– Participate in research or scholarly activity
• Most programs require completion of a research
project and an “educational” project
– Learn basic research methodology
E.M. Residency Educational
Program Requirements (cont.)
• Resident physician Wellness
– One of the main Program Director
responsibilities
– Balance personal and professional activities
– Provide support for stress, circadian
rhythms, and substance abuse problems
– Residents must be pre-notified as to how to
access support services
Helpful Specific E.M. Faculty
Roles to Consider
• Assistant or Associate Program Directors
(obviously at least one designee is needed to
run the Program when the Director is not
present ; Programs with more than 18
residents often utilize one Assistant or
Associate per each additional 8 to 10
residents).
• Medical Student Rotation Director.
• Director for “Off-Service” residents in the E.D.
Additional Helpful E.M. Faculty
Role Assignments to Consider
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Research Director
Didactic Conference Series Director
E.M.S. Director
Quality Improvement Programs Director
Official Liaisons to other clinical
departments
• Assigning each resident to a Core
Faculty person to act as the primary
“counselor” for each resident
Additional E.M. Department
Choices to Consider
• Should involve conjoint decision by the
Dept. Director and the Program Director :
– Medical student rotation(s) in the E.D.
– “Off-Service” resident rotations in the E.D.
– Having additional “Combined” residencies
(i.e., E.M.-I.M., E.M.-Peds, etc.)
– Having postgraduate fellowship(s) ( see next
slide)
Choices for E.M. Fellowship Training
Programs (following E.M. residency)
Emergency Medical Services (Prehospital care) : 1 to 2 years
Toxicology : 2 years (separate subspecialty certification)
Pediatric E.M. : 2 years
E.M. Research : 1 to 2 years
E.M. Administration : 1 year
E.M. Education : 1 year
Hyperbaric Medicine : 1 year
Sports Medicine : 1 to 2 years
Critical Care (Intensive Care) Medicine : 1 to 2 years
Aeromedical Care : 1 year
International E.M. : 1 to 2 years (may include obtaining an
M.P.H. degree)
Dedicated E.M. faculty director(s) needed
for any of these
E.M. Program Director Options for
Interviewing Resident Candidates
• ? Who performs initial application screening to
decide on interview invitations
• ? Use limited number of faculty to do
interviews or all faculty as available
– ? Have E.M. residents also interview
• ? Have interviews on “E.M. conference day” or
other days
• ? Conduct the initial interview(s) in “blinded”
mode
• ? What type of rank scoring system to use
Suggested Rank Order of
Items to Consider in Ranking
E.M. Residency Applicants
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4th year E.M. clinical rotation(s) grade(s)
Other clinical rotations grades
Letters of recommendation
Interview
Personal statement
Board scores
Preclinical course grades
Use of a combined numerical scoring system rating each of
these items, with additional point scores for research or other
unusual items, has proved useful for many Programs
The Extremely Important Position
of E.M. Residency Program
Coordinator
• The “right hand person” for the Program
Director
• Success of the residency may depend almost
as much on this person as on the Program
Director
• Responsible for office components of the
Program, to include :
– Resident candidate interviewing
– Resident, faculty, and Program evaluations
– Resident procedure lists and test results files
The Six General Competencies the
American Board of Medical Specialties
Has Tasked All Specialties to Evaluate
ƒ Patient care
ƒ Medical knowledge
ƒ Practice-based learning &
improvement
ƒ Interpersonal & communication skills
ƒ Professionalism
ƒ Systems-based practice
So the Evaluation(s) of residents’ and students’ clinical
performance should be linked to these 6 items
Example July Orientation for E.M. R1’s
in the Penn State Hershey Program
• 10 E.D. shifts
• 25 hours of didactics
• 26 hours of lab experience
– Live animal procedure lab
– Casting lab
– Mannequin Simulation Labs
– Ultrasound course
– Slit lamp lab
– Epistaxis control lab
• Life Lion Helicopter Fly - Along 1 to 2 days
• “Nurse for a Day” in the E.D.
Education / Scholastic Endeavour
Requirements of the Penn State
Hershey E.M. Program
• Project required for graduation
– Original Research or Evidence Based
Medicine review
– Presented at research conference in June
• Supervised by predesignated faculty
• Presentations at regional or national
conferences departmentally funded
Sample Rotation Schedule for the
Penn State Hershey E.M. Program
EM-1
EM-2
EM-3
4 mo. EM
6 mo. EM
4½ mo. EM
Anesthesia
2 mo. Community ED (HH)
1½ mo. Administrative EM
Internal Medicine
SICU
2 mo. Community ED (HH)
Cardiology
Toxicology (HH)
Trauma / General Surgery
MICU
EMS
PICU
Ob-Gyn (HH)
Orthopedics
Selective
Trauma / General Surgery
Elective
Pediatric Surgery
Pediatrics
(HH = “Harrisburg Hospital”, an affiliated local hospital)
Sample E.M. Resident Work
Schedule in the Penn State Program
• 9 hour shifts (overlapping with next shift
starting at hour 8)
• EM-1 : 23 shifts (48 hours / week)
EM-2 : 22 shifts (46 hours / week)
EM-3 : 21 shifts (44 hours / week)
• 4 months with call intern year
2 months with call 2nd year
2 months with call 3rd year
Sample Evaluation Scheme Used
in the Penn State Program
• Annual review with Program Director
• Quarterly meeting with faculty advisor
– Quarterly emergency faculty consensus
evaluations
– Off-service evaluations
– Direct observation forms
– Chart reviews
– Procedure logs
– Follow-up logs
– Quiz scores
– Research project progress
The American Board of E.M.
(A.B.E.M.) In-Training Exam
ƒ Given once per year (February) to all E.M.
residents at their residency site
ƒ Similar in length and content to the A.B.E.M.
certification exam
ƒ Helps prepare residents for the certification
exam
ƒ Allows Program Directors to identify areas
of knowledge deficit in their residents which
may then alter the residency curriculum,
and allows comparison to other residencies
Benefits of Training Other
Specialty Residents in E.M.
Allows ability & confidence in managing basic
emergencies.
Familiarizes them with E.D. operations and needs.
Improves working relationship with E.M. faculty &
E.M. residents.
Allows them to learn cost-effective use of ancillary
tests.
Provides an educational service to their “home”
departments (can be considered “educational
payback” for their departments having E.M.
residents on their inpatient rotations).
General Recommended E.M. Training
for Residents from Other Specialties
Internal Medicine, Family Practice :
–1 month in 1st year, 1 month in 2nd or 3rd year
General or Orthopedic Surgery, Anesthesia,
Otolaryngology :
–1 month in first year
Obstetrics & Gynecology , Pediatrics :
–1 month in 2nd or 3rd year
Radiology, Pathology, Psychiatry,
Ophthalmology :
–May NOT need an E.M. rotation
Considerations for an International
Clinical Rotation for the E.M.
Residents
• Resident work time for international rotations
is not paid to the Program by Medicare
• Does meet the goals of the six Core
Competencies
• Best reference list of rotations is on the
A.C.E.P. International E.M. Section sub-web
site ; E.M.R.A. is also accumulating a new list
• Shown to be an attractive feature for
residencies with applicants
Career Options for E.M. Residents
Graduating from U.S. Programs
Private practice
–Single hospital physician group
–Multi-hospital physician group
Academic practice
–Mix of clinical work, teaching, research
–Focus on research
Administration
–E.D. director
–Prehospital system director
Additional fellowship training
Locum tenens work
Program Directors
should be able to
prepare their
residents for any
of these
How to Run an E.M. Residency
Program : Summary
• The most important ingredient for a
successful residency is an enthusiastic,
dedicated, and knowledgeable Program
Director assisted by an energetic Program
Coordinator.
• Successful E.M. residency operation depends
on monitoring and maintaining high quality in
each of the many structural and human
components of the residency.