Rotating Resident Didactics in the Emergency Department: A Cross-sectional Survey on Current Curricular Practices

Authors


  • Presented at the Society for Academic Emergency Medicine annual meeting, New Orleans, LA, May 2009.

  • Funded by the Emergency Medicine Foundation Resident Research Grant, 2008–2009 (JBB), NHLBI 5K23HL077404-05 (DMC).

  • Supervising Editor: John Burton.

Address for correspondence and reprints: Amer Z. Aldeen, MD; e-mail: ameraldeen@gmail.com.

Abstract

Objectives:  Rotating (non–emergency medicine [EM]) residents perform clinical rotations in many academic emergency departments (EDs). The primary objective of this work was to quantify characteristics of rotating residents and the didactic curricula offered to them during their EM rotations. Secondary objectives were to identify barriers to instituting such didactics and to establish ideal curricular contents.

Methods:  A Web-based survey was administered by e-mail to residency directors of all U.S. allopathic EM residency programs. Consent was obtained in the first part of the survey, and the study was deemed exempt from full review by the institutional review board. Questions solicited information regarding type and quantity of rotating residents in their main EDs, the “didactic educational format” available to rotating residents, and ideal and actual didactic curricular contents. Statistics were reported as proportions and means with 95% confidence intervals (CIs) and medians with interquartile ranges (IQRs).

Results:  Surveys were sent to 143 programs, and the response rate was 71%. Ninety-nine percent of respondents had rotating residents in their EDs, and the median number per month was 4 (IQR = 3–6). Five percent of respondents had established didactic curricula specifically for rotating residents, and 64% sent them to either EM resident or medical student lectures. Thirty-one percent of programs reported no didactics, and 65% of these felt there was no need for such education. Resuscitation, trauma, and toxicology were cited as the most important subjects for actual and ideal curricula.

Conclusions:  Most academic EDs have rotating residents, but very few provide didactic education specific to their learning needs and almost a third provide no didactics.

ACADEMIC EMERGENCY MEDICINE 2010; 17:S49–S53 © 2010 by the Society for Academic Emergency Medicine

Medical educational experts agree that a well-designed graduate medical curriculum involves broad clinical experiences combined with a robust didactic component.1 Given the high patient volume, ready availability of diagnostic testing, and large variety of patient presentations, the emergency department (ED) undoubtedly provides a rich learning environment for clinical education.2 Over the past few decades, significant advancements have helped to define a suitable core didactic curriculum for emergency medicine (EM) residents.3

However, EM residents are not the only house officers who do clinical rotations in the ED. Rotating residents also receive the educational benefit of multiple patient encounters while providing valuable clinical service to promote optimal patient flow. Clinical experience in evaluating and managing acutely ill patients is a requirement for residency training in many specialties. The residency review committees of six specialties mandate rotations in the ED, and another eight recommend them.4

While didactic core curricula have been developed for EM residents and even medical students,5 little attention has been given to the didactic education of rotating residents during their EM rotation until recently.2,6,7 In 1984, Sanders and Kobernick2 argued in favor of a didactic curriculum for internal medicine (IM) residents rotating through the ED. A quarter century later, Kessler et al.7 presented a comprehensive curriculum using a validated needs assessment tool and EM and IM expert opinion.

Despite this recent curricular advancement, it is still unclear how many rotating residents provide clinical service in academic EDs or what didactics they receive. To our knowledge, only one study has described some of the characteristics of rotating residents in the ED.8 In this survey of academic EM educators, Lovett et al.8 found that 97% of academic EDs had IM rotating residents, and the majority of these were PGY-1 residents. IM rotating residents attended EM resident conferences in just over a third of academic EDs, IM conferences in a fifth, and both in a quarter. The authors did not discuss characteristics of non-IM rotating residents or reasons for the observed variability in didactic curricula.

Before academic EM educators consider applying a didactic curriculum for rotating residents, we must first characterize our learners and the current state of their education. The primary objectives of this study were to describe the type and numbers of rotating residents in academic EDs across the country and the didactics offered to them. Secondary objectives were to identify barriers to instituting such didactics and to establish ideal curricular contents.

Methods

Study Design and Population

This was a Web-based survey of residency leaders (program directors, associate/assistant program directors, or other designated representatives) of the 143 Accreditation Council for Graduate Medical Education–approved EM residency programs. Consent was obtained in the first part of the survey. This study was deemed exempt from full review by the institutional review board of Northwestern University.

Survey Content and Administration

Responses were collected over a 3-month period from March 2008 through May 2008 using SurveyMonkey, an online survey program. Nonresponders to the initial e-mail were sent two repeat invitations separated by 2 weeks until a response was obtained or the enrollment period ended. When multiple replies from a single program were received, respondents were asked to clarify their answers. If no clarification was given, the reply of the most senior respondent was used. Contact e-mail addresses were obtained from publicly available sources.

The survey questions targeted three domains: 1) characteristics of rotating residents who performed clinical rotations at the primary ED, 2) type of didactic education offered to these rotating residents, and 3) didactic subject matter in existing (and proposed) curricula. Respondents who offered didactic education to rotating residents were asked further questions regarding attendance policy, evaluation, orientation, and learning objectives. Respondents without didactics were asked to specify reasons why no didactics were offered and barriers that may have prevented their implementation.

Data Analysis

Statistical analyses were performed using Stata Ver. 9 (StataCorp, College Station, TX). Proportions and mean values are reported with 95% confidence intervals (CIs) and median values with 25–75 interquartile ranges (IQRs).

Results

Of the 143 eligible subject programs, 101 (71.1%, 95% CI = 63% to 78%) responded with complete data. All but one respondent reported having rotating residents in their main ED, yielding a total sample of 100. The median number of rotating residents per month was 4 (IQR = 3–6). Five percent of respondents indicated the presence of a rotating resident-specific didactic curriculum.

The most common type of rotating resident reported by respondents was categorical IM, followed by obstetrics-gynecology, transitional or preliminary IM, subspecialty surgery, family medicine, pediatrics, and general surgery (see Table 1). Based on their responses to the questions about didactic curricula offered to rotating residents, respondents were classified into four groups: rotating resident–specific didactics (5%), inclusion of the rotating residents in medical student lectures (6%), inclusion of rotating residents in EM resident lectures (58%), and no didactics (31%; see Figure 1 and Table 2).

Table 1. 
Characteristics of Rotating Residents in Academic EDs
ED CharacteristicValue
  1. IQR = interquartile range; IM = internal medicine; OB/GYN = obstetrics and gynecology.

Median EM residents per month (IQR)12 (10–15)
Median rotating residents per month (IQR) 4 (3–6)
Median medical students per month (IQR) 5 (4–8)
Mean ED beds (95% CI)48 (42–55)
Mean ED patients per year (95% CI)70,950 (66,146–75,754)
Rotating Resident Specialty (Alphabetical Order)% Academic EDs With Given Rotating Resident (95% CI)
Family medicine50 (40–60)
IM
 Categorical92 (85–96)
 Preliminary/transitional67 (57–75)
OB/GYN68 (58–76)
Pediatrics35 (26–45)
Surgery
 General21 (14–30)
 Subspecialty52 (42–62)
Other39 (30–49)
Figure 1.

 Different didactic curricula offered to rotating residents. RR = rotating resident.

Table 2. 
Characteristics of Rotating Residents Sorted by Didactic Education Offered
GroupCumulative (n = 100)Rotating Resident–specific Didactics (n = 5)Medical Student Lecture (n = 6)EM Resident Lecture (n = 58)No Didactics (n = 31)
  1. IQR = interquartile range.

Median EM residents/month (IQR)12 (10–15) 11 (10–15) 11 (7–14)13 (11–15)12 (10–14)
Median rotating residents/month (IQR) 4 (3–6)  6 (4–6)  4 (2–6) 4 (3–6) 4 (2–6)
Median medical students/month (IQR) 5 (4–8) 10 (6–12)  6 (5–8) 5 (3–8) 6 (4–9)
Mean ED beds (95% CI)48 (42–55) 50 (24–75) 52 (36–68)49 (38–60)46 (39–53)
Mean ED patients per year (95% CI)70,950 (66,146–75,754) 70,000 (50,368–89,632) 73,333   (43,899–102,768)67,931 (62,278–73,585)76,290 (65,639–86,942)
Orientation provided, % (95% CI)81 (72–87)100 (57–100)100 (61–100)83 (71–90)71 (53–84)
Lecture attendance required, % (95% CI)N/A 80 (38–96) 33 (10–70)50.0 (38–62)N/A
Evaluation instrument, % (95% CI)N/A 60 (23–88) 33 (10–70)14 (7–25)N/A

When questioned about the barriers to establishing didactic education for rotating residents, the majority of respondents without didactics (65%) felt that there was no need to provide such education, almost one-third (29%) cited lack of available resources, and a small minority (6%) indicated lack of available interested faculty (Figure 2). If a premade online didactic curriculum were provided to respondents without didactics, 45% (95% CI = 29% to 62%) would favor its use, 45% (95% CI = 29% to 62%) were neutral, and 10% (95% CI = 3% to 25%) would disfavor its use.

Figure 2.

 Reasons for no didactics for rotating residents.

The most frequently recommended didactic subjects for rotating resident education were trauma, toxicology, resuscitation, cardiopulmonary procedures, and orthopedics (see Table 3). Eighty-one percent of all respondents provided procedural training for medical students, and 25% reported such education for rotating residents.

Table 3. 
Didactic Curricular Subjects Offered/Recommended
Didactic SubjectRotating Resident–specific Didactics, % (95% CI)Medical Student Lectures, % (95% CI)No Didactics, % (95% CI)
  1. CV = cardiovascular; ENT = ears, nose, and throat; Heme-Onc; hematology & oncology; OB/GYN = obstetrics and gynecology.

  2. *Top five.

CV/pulmonary40 (12–77)83 (44–97)*84 (67–93)*
Dermatology0 (0–43)0 (0–39)0 (0–11)
Endocrine0 (0–43)17 (3–56)0 (0–11)
ENT20 (4–62)17 (3–56)7 (2–21)
Environmental40 (12–77)17 (3–56)10 (3–25)
Genitourinary0 (0–43)17 (3–56)0 (0–11)
Gastrointestinal40 (12–77)50 (19–81)29 (16–47)
Heme-Oncol0 (0–43)0 (0–39)3 (1–16)
Allergy20 (4–62)0 (0–39)3 (1–16)
Neurology20 (4–62)50 (19–81)29 (16–47)
OB/GYN20 (4–62)50 (19–81)23 (11–40)
Ophthalmology80 (38–96)*33 (10–70)10 (3–25)
Orthopedics60 (23–88)*83 (44–97)*29 (16–47)
Pediatrics20 (4–62)33 (10–70)10 (3–25)
Procedures40 (12–77)67 (30–90)*32 (19–50)*
Psychiatry0 (0–43)17 (3–56)10 (3–25)
Resuscitation80 (38–96)*83 (44–97)*87 (71–95)*
Toxicology80 (38–96)*67 (30–90)*39 (24–56)*
Trauma80 (38–96)*83 (44–97)*65 (47–79)*
Vascular20 (4–62)17 (3–56)16 (7–33)

Discussion

Our study quantifies the characteristics of rotating residents in academic EDs across the nation and describes the state of their didactic education during their EM rotations. All but one of the EM residency programs that responded to our survey had rotating residents in their primary ED. However, only 5% of respondents reported a specific didactic curriculum for their rotating residents.

The median numbers of rotating residents and EM residents per month were 4 and 12, respectively. Therefore, rotating residents comprised roughly a quarter of the total monthly housestaff in the ED. It is thus likely that rotating residents provide care for many ED patients, underscoring the importance of comprehensive education for these residents. Educational experts in EM and other specialties agree that appropriate curricular design for housestaff must include didactic instruction in addition to clinical experience.1,2,7,9 Despite the widespread prevalence of rotating residents in our survey, only 5% of academic EDs offered didactic education targeted to their educational needs.

Several prior studies indicate that the learning objectives of rotating residents are difficult to predict and may be significantly different from those of EM residents.10–12 Because of this and variations in background EM knowledge and clinical skills, it is doubtful that most rotating residents benefit significantly from didactics intended for EM residents. Didactic content intended for medical students may be more appropriate for rotating residents, given the emphasis on principles of EM that every future physician should know regardless of specialty. However, these curricula do not account for clinical experience already attained by rotating residents during their non-EM rotations and may be overly theoretical.

Nearly two-thirds of respondents without didactics felt that there was no need for such education. Our survey did not specifically query reasons for this, but several possibilities exist. Perhaps these respondents felt that rotating residents were less interested in EM didactics and more focused on their own specialty’s educational requirements. The heterogeneity of the rotating resident pool may render a single didactic program less applicable to all rotating residents. Other potential reasons include the perception that rotating residents do not “deserve” didactic education either because they are not long-term members of the ED team or because they do not see a significant proportion of ED patients. Finally, the presence of contentious interdepartmental relationships may limit enthusiasm for cooperative education.

We also sought to determine whether respondents without didactics would choose to provide such education if a premade curriculum were available online. More of these respondents (45%) were in favor of using such a premade curriculum than opposed to it. Among the 20 respondents who stated that there was “no need” for rotating resident didactics (rather than “no resources” or “no available faculty”), 45% were in favor of using a premade curriculum. This suggests that faculty time and resources are, in fact, major limiting factors for why many academic EDs do not offer didactics to rotating residents. Therefore, a standardized didactic curriculum available in online format may be instrumental in the education of rotating residents.

Based on their responses to actual and ideal didactic subjects, resuscitation, trauma, and toxicology were rated as the most important by all respondents (see Table 3). Orthopedics was offered by most respondents with rotating resident-specific and medical student didactics, but was not rated as highly by respondents with no didactics. Cardiopulmonary was offered by most respondents with medical school didactics and valued highly by respondents without didactics, but fewer than half of the curricula of respondents with rotating resident-specific didactics contained such material. Perhaps because most rotating residents are IM, respondents with rotating resident-specific didactics feel that providing education in cardiopulmonary emergencies is less necessary. Future work can focus on comparing these results with opinions of non-EM educators and rotating residents themselves to help optimize curricula such as that proposed by Kessler et al.7

Limitations

Survey data were limited by selection bias, assessing only those subjects who chose to participate. Many programs lacking rotating residents may not have responded. However, because little data have been published on characteristics and education of rotating residents in the ED, a survey was chosen as the most ideal format. Also, no osteopathic EM programs were included in the survey; information regarding rotating residents in those programs is still unknown.

Another limitation of our survey instrument was inclusion of an upper cap to the questions regarding number of total EM residents and rotating residents per month (i.e. “17 or more”). This limited our ability to measure the number of programs that had extremely high numbers of rotating residents in their main ED and necessitated the use of median instead of mean values.

Only respondents without didactics were queried about the barriers to instituting didactic curricula for rotating residents. Respondents with rotating resident-specific didactics may have provided valuable recommendations about their experience in overcoming specific barriers. Additionally, specific barriers may have forced other respondents to send rotating residents to medical student or EM resident conferences.

Respondents who send rotating residents to EM resident lectures were not asked about ideal subjects in a curriculum for rotating residents. We assume that these respondents value EM residency didactics as more important than rotating resident-specific didactics, which may not be the case.

We did not consider the possibility that some academic EDs might allow rotating residents to attend their respective departmental conferences. Some academic EDs may believe that rotating residents do not require EM-related didactic exposure and should instead focus on the educational goals of their own specialties.

The small number of respondents with either medical student (n = 6) or rotating resident-specific didactics (n = 5) makes generalization of their responses difficult. However, this serves to further highlight the paucity of academic EDs that have focused didactics for their rotating residents.

Conclusions

This study demonstrated that rotating residents represent a significant proportion of total housestaff in academic EDs and that their didactic education is rarely specific to their educational needs. Future studies should focus on determining what educational experts in non-EM specialties feel are the most important didactic learning needs for their residents during the EM rotation. Combining this information with EM expert opinion2,7 and rotating resident self-assessment10–13 should allow EM educators to establish ideal didactic curricula for rotating residents. These curricula may be tailored to the needs of individual rotating residents depending on their specialty or objectively tested knowledge deficits.14

The authors thank the Emergency Medicine Foundation for its generous support of this study. They also acknowledge Steve Zahn, MD, and Andrew Foster, MD, for their help on this paper.

Ancillary