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Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

Objectives:  Emergency medical services (EMS) was recently approved as a subspecialty by the American Board of Medical Specialties, highlighting the core content of knowledge that encompasses prehospital emergency patient care. This study aimed to describe the current state of EMS education at emergency medicine (EM) residency programs in the United States.

Methods:  The authors distributed an online survey containing multiple-choice and free-response questions pertaining to resident EMS education to the directors of EM residency programs in the United States between July 21 and September 10, 2010.

Results:  Of 154 programs, 117 (75%) responded to the survey, and 108 (70%) completed the survey by answering all required questions. Of completed surveys, 82 programs (76%) reported the cumulative time devoted to EMS didactic education during the course of residency training, a median of 20 hours (range = 3 to 300 hours; interquartile range [IQR] = 12 to 36 hours). There is a designated EMS rotation in 89% of programs, with a median duration of 3 weeks (range = 1 to 9 weeks; IQR = 2 to 4 weeks). Most programs involve residents on EMS rotations strictly as in-field observers (63%), some as in-field providers (20%), and the rest with some combination of the two roles. Ground ride-along is required in 94% of programs, while air ride-along is mandatory in 4% and optional in 81% of programs. Direct medical oversight (DMO) certification is required in 41% of residency programs, but not available in 26% of program jurisdictions. Residents in 92% of programs provide DMO. In those programs, most residents (77%) provide DMO primarily while working in the emergency department (ED), 13% during dedicated EMS or medical oversight shifts, and 4% during a combination of these shifts. Disaster-preparedness was most frequently listed as the component programs would like to add to their EMS curricula.

Conclusions:  There is a wide range in the didactic, online, and in-field EMS educational experiences provided as part of EM training. Most residents participate in ground ride-along activities, provide DMO, and have a dedicated EMS rotation. Disaster-preparedness is the most common desired addition to existing EMS rotations.

ACADEMIC EMERGENCY MEDICINE 2012; 19:1–6 © 2012 by the Society for Academic Emergency Medicine

The recent establishment of emergency medical services (EMS) as a subspecialty by the American Board of Medical Specialties underscores the unique body of knowledge that encompasses out-of-hospital emergency care. As this care is closely tied to the management of patients in the emergency department (ED), the Accreditation Council for Graduate Medical Education (ACGME) program requirements for emergency medicine (EM) already include baseline elements of EMS education.1 These include paramedic base station communication, in-field care and transportation, and training of prehospital providers. However, in spite of these common requirements, a variety of disparate residency curricula have been published for providing EMS education, and there is a lack of consensus on the optimal content and methods for providing this education.2–9 Furthermore, a survey of 737 EM residents by Willoughby et al.10 identified that a majority thought that EMS was poorly integrated into their curriculum.

To serve as a foundation for the development of an updated and standardized curriculum for graduate medical education in EMS, we aimed to assess the current practices and capabilities of United States residencies for providing EMS education. Using an online survey of EM residency program directors, we attempted to identify the didactic and experiential activities currently provided on a mandatory or optional basis to EM residents and the components that program directors believed were needed to improve resident EMS education.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

Study Design and Population

We distributed a cross-sectional, anonymous survey. This study received institutional review board approval through the sponsoring institution. We distributed this survey to program directors of accredited EM residency programs in the United States. We contacted program directors for participation by e-mail, using contact information maintained by the Society for Academic Emergency Medicine (SAEM). A letter of support from the Council of Emergency Medicine Residency Directors (CORD) accompanied the initial communication to encourage participation. The e-mail message did not provide any incentive for participation. The introductory e-mail message included an electronic link as well as an opt-out option. We distributed follow up e-mails to nonresponders weekly for 1 month. The program directors of programs that did not respond to any of the e-mail messages were then contacted by phone and asked to identify a member of the faculty who was actively involved in the program’s EMS education. We then e-mailed that faculty member the survey link. If there was no response to the survey after two follow-up e-mails to the EMS faculty member, the program was considered a nonresponder.

Survey Content and Administration

The survey aimed to assess both the required and the optional components of EMS education in United States EM residency programs. This survey consisted of multiple-choice and free-response questions. Survey questions included the structure of the resident EMS curriculum including number of didactic hours, the medical oversight requirements, and the availability of an EMS fellowship program. Responders were asked to identify the individual components of their programs’ EMS rotations that were required and/or available, any text used, and the methods of feedback. The rotation components that residents reported as being the most meaningful as well as least meaningful were also reported on, as were the components that responders felt their program should have more of (the survey questions are available in Data Supplement S1, available as supporting information in the online version of this paper). The survey was created with input from members of the SAEM EMS Interest Group and was reviewed by the board of directors of CORD. Of the 25 survey questions, 21 were designated as required.

We distributed an electronic survey using a commercial online survey program (SurveyMonkey, http://www.surveymonkey.com). We compared responders versus nonresponders by program location, program (PGY) structure, number of residents per class, and number of years in existence, based on information available through the SAEM and the ACGME.

Data Analysis

Data were analyzed by descriptive statistics using a commercially available spreadsheet program (Microsoft Excel 2007, Microsoft Corp., Redmond, WA). Programs that did and did not respond to the survey were compared using chi-square tests (program location, program structure) and t-tests (number of residents, number of years in existence) using STATA 11.0 (StataCorp LP, College Station, TX).

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

Of the 154 EM programs surveyed, 117 (75%) responded and 108 (70%) answered all of the required questions. Responders and nonresponders were similarly matched by program location, program structure, number of residents per class, and number of years in existence (Table 1). Most of the programs surveyed (99%) were accredited by the ACGME, and two programs were accredited by the American Osteopathic Association. Of those that completed surveys, 82 (76%) reported their aggregate number of hours dedicated to EMS education during residency training and reported a median of 20 hours (range = 3 to 300 hours; interquartile range [IQR] = 12 to 36 hours). Only 11 programs have a designated EMS textbook. The majority of programs (89%) have an EMS rotation, with a median duration of 3 weeks (range = 1 to 9 weeks; IQR = 2 to 4 weeks). Of those programs with a designated rotation, 63% offer the entire rotation during one of the program’s training years.

Table 1.    Characteristics of Participating and Nonparticipating Programs in the Survey
 Responders (%)*Nonresponders (%)p-value†
  1. *Includes complete and partial responders.

  2. †p-value of chi-square test (program location, program structure) or t-test (residents per class, years in existence).

Program location
 Northeast32270.624
 Midwest2822
 South2635
 West1416
Program structure
 PGY 1–370760.988
 PGY 1–42022
 PGY 2–4 3 3
Residents per class
 Mean (range)11 (4–20)11 (6–24)0.682
Years in existence
 Mean (range)20 (1–41)22 (2–40)0.370

Most EMS rotations involve residents strictly as in-field observers (63%), some as in-field providers (20%), and the rest with some combination of the two roles. The majority of programs that offer a rotation involving air medical transport classified that portion as optional (Table 2) (82% optional as third crew member/observer, 12% optional as second crew member), with fewer requiring participation (3% required as third crew member/observer, 2% required as second crew member). Additional components that residency programs provide include tactical medicine, vehicle extrication training, search and rescue experience, and an EMS scholarly track.

Table 2.    Mandatory and Optional Components of Resident EMS Rotations
Activities of EMS RotationPercent of Programs Where Activity Is MandatoryPercent of Programs Where Activity Is Available and OptionalAt Programs Where It Is Optional, Median Percentage of Residents Who Participate (IQR)
  1. DMO = direct medical oversight; IQR = interquartile range.

Ride-along
 Ground94520 (5–25)
 Air48118 (5–50)
DMO86650 (25–100)
Education of prehospital health care providers643425 (10–50)
Mass gathering events (e.g., football games, marathons, etc.)217020 (10–45)
EMS quality improvement534010 (5–23)
Disaster-preparedness573820 (10–40)
Dispatch observation473110 (5–25)
Physician response vehicle11185 (1–10)
Wilderness medicine54515 (5–24)

Direct medical oversight (DMO) certification is required of residents in 41% of programs, while this certification does not exist in the jurisdiction of 26% of surveyed programs. Residents receive mandatory or optional experience providing DMO in most programs (92%). Of the programs where residents provide DMO, the majority (77%) have the residents primarily do this as part of their shifts in the ED, while some (13%) have dedicated EMS or medical oversight shifts, a few (4%) use both ED shifts and dedicated shifts, and a few (6%) use other means to provide this experience.

Emergency medical services fellowships exist in 39% of programs surveyed, with 7% of the remaining programs planning to include one in the future. Half of the programs with a fellowship program reported having the position filled, and only 11% had the position filled during all of the preceding 3 years. Fifty-two percent of residency programs reported sending at least one resident to an EMS fellowship in the past 5 years.

There were 88 responders who provided free-text responses identifying the most meaningful component of their EMS rotation (multiple responses allowed and nonresponders included those without an EMS rotation or with a new EMS rotation). In-field experience, most commonly by ground ride-alongs, was identified by most responders (69%) as the most meaningful rotation component to residents, followed by DMO (19%), teaching EMS providers (8%), air medical services (7%), disaster management (6%), mass gatherings (3%), didactics (2%), and other components (11%). Conversely, 19 responders (22%) reported ground ride-alongs as the least meaningful component, with down time between calls specifically mentioned as a weakness. Dispatch observation was also commonly reported as the least meaningful aspect.

Responders commonly identified disaster planning and additional DMO experience as the components they would want to add to their curricula (recommended by 10 and 6% of responders, respectively), while 44% of responders offered no recommendation for improvement. The top three barriers to a successful rotation listed were time (32%), money (20%), and malpractice (5%). Thirty-three percent of programs reported no barriers. Responders identified a variety of issues that should be considered when establishing a model resident EMS education curriculum, which clustered along common themes. Responders would like a flexible curriculum that allows the program to take advantage of its local EMS resources. Many expressed concern that a standard curriculum could result in too many restrictive requirements. Several expressed interest in a rotation that is distributed over the course of residency to allow residents to grow with their experience. Despite having few programs that use residents as in-field providers, several responders indicated that this role possessed a significant advantage over observation. Several responders also recommended the creation of online core learning modules that could be accessed for the rotation.

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

The anticipated establishment of an EMS subspecialty by the American Board of Medical Specialties prompted the SAEM EMS Interest Group to reassess the model curriculum in EMS for EM residency programs previously published by SAEM.6 As part of this process, we aimed first to assess the EMS-related educational experiences EM residents currently receive during training, as well as input from program directors on what components are viewed by residents as most useful. These data provide information on current educational capabilities and input from experts in resident education about how best to deliver this unique body of knowledge to graduate trainees.

The ACGME has identified EMS education as a required component of EM training and, as a core component of systems-based practice, the sixth competency outlined by the ACGME Outcomes Project.1,11 In addition to the SAEM model curriculum,6 a number of other model curricula for EMS education have been published.2–5,7–9 Model curricula and program descriptions have focused primarily on the provision of medical oversight, quality assurance and improvement activities, education of EMS providers, and in-field observational experiences.2,3,6,8,9 However, a variety of other more active experiences have also been described, including resident integration as an in-field provider within a ground or air EMS system and unique experiences within urban, rural, or wilderness environments.7,12–17

Variation in recommendations among published curricula stems from a lack of data on what components of resident EMS education are most important to emergency physicians’ future medical practice. Expert opinions outlined in prior curricula have identified a core set of EMS education components that should be part of residency training, and this is consistent with the recommendations published by Verdile et al.6 on behalf of the SAEM EMS Committee in its model EM residency EMS curriculum.3–6,8,9 Verdile et al.6 outlined a set of “absolute minimum training” requirements for residents, including “competency in providing off-line (indirect) and on-line (direct) medical direction to EMS personnel.” Yet, our data reveal that 14% of residency programs do not require participation in DMO. Verdile et al. further suggested a diverse EMS educational experience to obtain an understanding of the structure of EMS systems, their various components, and capabilities. Their model curriculum outlines 21 hours of didactic instruction in various EMS topics and recommends experience in out-of-hospital emergency care, routine participation in base-station radio direction, and active involvement in the training of EMS personnel.6 Our data reveal that half of EM residencies do not provide the previously suggested amount of EMS didactics, while others provide much more than the recommended amount. While we did not collect information on what specific didactics are covered at individual programs, this suggests that many EM residency programs do not currently cover the breadth of topics that have been previously identified as core components for a broad understanding of EMS systems and their contribution to systems-based practice in the ED.

The recommended amount and type of hands-on experience in out-of-hospital care is less well defined, with various published recommendations including involvement in air or ground direct patient care activities and involvement in mass gathering activities and as medical directors for EMS agencies.4,7–9,12–14,16–19 In a survey of U.S. and Canadian residency programs, Ray and Sole20 identified that a majority (88%) of programs require observation with ground EMS, while working as an EMS provider is required in 28%. Only 16% reported helicopter-based EMS involvement.20 We found similar percentages of programs requiring ground ride-alongs and offering air medical ride-along activities. We also found a similar percentage of residents involved in DMO and mass gathering medical care. Our study built on this prior work by identifying whether these activities are currently mandatory or available at all, as well as providing additional information into the didactic and other experiential activities that form part of resident EMS curricula.

Some similarities do exist in the types of activities provided during EMS rotations, with most taking part in ground ride-along activities and many responders reporting their residents’ view of ground ride-alongs as the most meaningful component of an EMS rotation. Still, other programs emphasize the importance of working as a provider in the EMS setting and downplay the utility of only functioning in an observer capacity where this is the only option available. Where hands-on patient care cannot be provided by residents in the field due to logistic or medicolegal considerations, in-field observation may provide a level of understanding of the out-of-hospital setting and medical care that cannot be obtained through didactic, medical oversight, or other indirect patient care activities. Still, it appears that residents at some programs report a lack of value to ride-along shifts, which may be due to down time between EMS responses, lack of physician hands-on involvement in some EMS systems, and difficulties with integrating individual EM residents into EMS systems for participation in only brief out-of-hospital rotations.

We identified disaster preparedness and additional DMO opportunities as commonly desired additions to existing EMS rotations. However, these are capabilities not easily available at some programs. Responders identified time, money, and malpractice as common barriers to maximizing an EMS rotation. These responses highlight the system-level coordination that is necessary for residents to have access to certain EMS activities. For example, if a primary teaching hospital is not a primary medical oversight facility for an EMS jurisdiction, residents will not have the opportunity to provide medical oversight at that training site. EMS rotation directors will face challenges to maximizing educational time and may lack malpractice insurance for residents to obtain this experience at another facility. We extrapolate that these limitations may be more prevalent in communities with multiple separate EM training programs, where individual facilities and faculty have established roles for indirect medical oversight, DMO, and disaster planning. We suggest increased collaboration among residency programs with differing faculty involvement in local and regional EMS systems to maximize the experience provided to residents as part of a comprehensive EMS training curriculum. In jurisdictions that allow residents to provide patient care as in-field responders, hands-on involvement may maximize the in-field experience in comparison to purely observational roles.

The best way to standardize EMS curricula as a part of EM training remains unanswered, as does the way EMS rotations will change as a result of EMS subspecialization. Additional research beyond expert opinion is needed to identify the components of an EMS curriculum that are most valuable as part of residency training and which components are more appropriate for subspecialty training after residency. We agree with the majority of our responders that it is important to have a flexible curriculum to best utilize local resources and provide the best education for residents while addressing common barriers of time and money. We recommend that programs that have limited interaction with EMS systems in their area form cooperative agreements with other residencies in their region to ensure the provision of basic components of EMS education outlined in prior curricula, such as the provision of DMO, and some experiential in-field EMS involvement. Future research is still needed to identify a minimum set of didactic topics and experiential activities that would best prepare emergency physicians to handle the EMS-related activities of their practice. Once evidence-based standards exist, an updated EMS curriculum should be created. Based on the didactic and experiential activities reported by responders of our survey, we anticipate most programs will be able to meet these minimum recommendations without increasing the time dedicated to EMS education in their curriculum. However, a minority of programs with limited EMS education may need to increase the time dedicated to this new subspecialty or combine EMS-related activities with existing rotations to meet minimum training recommendations for this component of systems based practice.

Limitations

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

This electronic survey–based study was limited in that it was not inclusive of all U.S. EM residency programs, and although there was a response rate of 70%, responder bias may have resulted in an overrepresentation of programs with a greater interest in EMS education. Based on program contact information available at the time of survey distribution, we distributed surveys to 152 allopathic and two osteopathic residency programs without intended exclusion of other osteopathic residency programs. Responses may not be representative of EMS education provided at other osteopathic EM residencies. Questions provided through electronic survey methods are limited by interpretation of questions and by the variable response rate to questions that are marked as “required” versus “voluntary.” Although surveys were all initially sent to program directors, some surveys were completed by the directors of the EMS rotation or other EMS faculty. We did not collect whether program directors or other faculty completed individual surveys, and this may have contributed to the variability of responses. While this survey answers questions regarding what EMS experiences are currently offered in EM training, and additional components that are desired by some, it does not address what additional or differing components could be provided by programs if a standardized curriculum or new requirements were developed.

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

There is a wide range of didactic, online, and in-field EMS educational experiences provided as part of EM training. Most residency programs have a dedicated EMS rotation and residents participate in ground ride-along activities and direct medical oversight. Disaster-preparedness is the most common desired addition to existing EMS rotations.

The authors thank Dr. Carin Van Gelder for her assistance in reviewing and editing the survey instrument. The authors would also like to thank Dr. Michael Beeson and the Board of Directors of the Council of Emergency Medicine Residency Directors for reviewing and supporting the distribution of the survey.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

Supporting Information

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References
  9. Supporting Information

Data Supplement S1. Survey questions of residency EMS education survey.

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