Final year medical students as Assistants in Medicine in the emergency department: A pilot study

To evaluate the Assistant in Medicine (AiM) programme and its impact on physician burden and productivity in the ED.


Introduction
In Australia, emergency physicians assess and treat acutely ill patients, while also completing administrative tasks including patient documentation, ordering pathology and imaging, and medication charting. 1 ED physicians also spend a considerable amount of time taking referrals, checking investigation results, and discussing patient management plans with junior medical officers. 1 The Assistant in Medicine (AiM) role is a part-time employment opportunity offered to final year medical students to provide medical care and support to patients as part of the multidisciplinary team. This role was developed in March 2020 as part of the New South Wales (NSW) Health COVID-19 plan to supplement the existing junior medical workforce in anticipation of potential staff redeployment for the COVID-19 pandemic. 2 The NSW Health AiM Evaluation Report states the most frequently undertaken tasks by AiMs were medical record documentation, preparing discharge summaries and organising consults. 2 The responsibilities of the relatively new AiM role are not unlike that of the medical scribe in the American healthcare system. Medical scribes in American hospitals are trained to perform documentation and gather patient information on behalf of a physiciana role that has been shown to increase the productivity of emergency physicians and reduces the time a patient spends in ED. [3][4][5] In Australia, however, medical scribes are utilised in only some private EDs and not in the public system. 3 In the ED, there is significant overlap in the role of a medical scribe and an AiM. 5 By working in conjunction with an AiM or medical scribe, emergency medicine physicians can focus on clinical assessment and management of patients allowing them to utilise their time more effectively without the added administrative burden, contributing to task overload and job • Seventy-seven percent of doctors found that AiMs increased their productivity as they were able to see more patients during a shift.
• Ninety-six percent of doctors were of the opinion that AiMs would be a useful permanent addition to the ED. • Further research on utilisation of AiMs is required to evaluate long-term impacts on emergency physician productivity.
dissatisfaction. 5 In contrast to medical scribes, medical students have the added benefit of being able to perform basic procedures and take clinical histories ( Table 1). As such, an ongoing AiM programme in EDs around Australia could have the potential to reduce physician burnout and increase their productivity. In Australian medical schools, emergency medicine is incorporated into final year clinical placement as a component of the critical care curriculum along with intensive care and anaesthetics. The Bachelor of Medical Science and Doctor of Medicine (Joint Medical Program) delivered by the University of Newcastle and University of New England encompasses 6-9 weeks of emergency medicine placement in the final year of the programme. Prior to their employment, AiMs are determined to have the required clinical competency and experience to work within a multidisciplinary hospital team as assessed by their medical school.
As the AiM programme is a relatively new addition to the NSW Health medical workforce, there is minimal research into its impacts on increasing emergency physician productivity. This presents a unique opportunity to evaluate current attitudes towards the AiM programme.
The aim of this study was to determine the impact of the AiM programme on reducing emergency physician administrative burden and increasing productivity in our tertiary level ED.

Setting
The Calvary Mater Newcastle ED in NSW, Australia employed eight final year medical students as part-time AiMs for a 10-week period from October to December 2021. This programme period overlapped with the final year emergency medicine placement at the end of the year. AiMs were employed by NSW Health and renumerated at 75% of the NSW Medical Officer Intern salary.
Each student in this ED worked one 10-h shift per week, inclusive of weekends. During these shifts, AiMs were assigned to assist one doctor of postgraduate year 3 or above with tasks including but not limited to documentation, patient reviews, hospital consults, procedures and discharge preparation. At the conclusion of each shift with an AiM, supervising doctors completed an online questionnaire of their experience.

Design
This survey-based cohort study is presented with quantitative descriptive statistics. It measures the subjective impact of the AiM programme on the number of patients seen by the doctor, physician productivity, physician stress, physicians' enjoyability during a shift and their perceived usefulness of AiMs as an addition to the medical workforce.

Ethics
The present study was approved for an exemption for ethical review of negligible risk research activities as authorised by Research Ethics and Governance Hunter New England Local Health District (AU202111-11) prior to commencement.
Recruitment for the AiM role occurred in collaboration with Local Health Districts, NSW medical schools and the Health Education and Training Institute. Local Health Districts received an allocation of COVID-19 funding for the AiM position and the establishment of a Director of Assistant in Medicine (DAiM) role to support the AiMs. 1 Prior to commencing employment, Calvary Mater Newcastle AiMs received a formal orientation onsite including review of safety protocols, use of person protective equipment with N95/P2 mask fitting and tour of the ED. AiMs were given a welldefined role and clear scope of practice in the ED, with strong support from the DAiM, ED and administrative staff. Possible tasks to be undertaken by AiMs were outlined during orientation, including in-room patient documentation, primary care information retrieval, facilitation of investigations, post-initial consultation tasks and discharge preparation with appropriate senior supervision.
Rostering and allocation of AiMs to supervising doctors were completed by the DAiM. From the 10-week period starting on 18 October 2021, AiMs completed at least one 10-h shift either from 7 am to 5 pm (morning shift) or 1 to 11 pm (evening shift) each week. In the present study, AiMs were only assigned to supervising doctors who were senior resident medical officers (SRMOs), registrars or career medical officers. Hours completed as an AiM were able to be credited for emergency medicine clinical placement hours to reduce student workload and prevent burnout by At the end of each shift, the supervising doctor was asked to complete an online questionnaire via Google Forms detailing their experiences with the AiM (Appendix S1). All doctors involved provided informed consent for participation in the present study.

Results
Forty-seven survey responses were completed, corresponding to eight AiMs completing 47 shifts with a 59% survey response rate (47/80). Of these responses, 28 doctors (60%) were registrars, 15 doctors (32%) were SRMOs, and four doctors (9%) were career medical officers. All AiMs assisted with scribing and discharge preparation (100%). Of the 47 AiM shifts completed, 46 AiMs (98%) were involved in ordering of investigations and 41 (88%) assisted with assessment of the patient including history and examination. The less common tasks performed by AiMs included procedural skills with 36 shifts involving cannulation (77%), 19 (40%) involving information retrieval and 12 involving hospital consults or referrals (26%) during the 10 weeks.
As seen in Table 2, most doctors found that AiMs increased their productivity during a shift with 77% seeing more patients compared to a normal shift. Furthermore, there were positive impacts on wellbeing with 100% of doctors finding their shifts enjoyable and 64% feeling less stressed at the end of a shift. Some responses to the recommendations and improvement question for the AiM programme (Question 8) are listed in Table 3. Forty-five percent of responses suggested continuation of the programme and 51% stated they had no suggestions, recommendations, or improvements.
Over the 10-week period, 96% of doctors confirmed that the use of final year medical students as AiMs or medical scribes would be a useful permanent addition to the medical workforce in the ED.

Discussion
The time required for documentation can be reduced by employing medical students in ED as scribes. Approximately 44% of an ED physicians' time is spent on data entry and only 28% on direct patient care. 6,7 Utilising medical students as medical scribes may allow physicians to allocate more time on patient care and management, while also benefitting the students in their medical experience and learning. 5,8,9 Delage et al. conducted a study of third-year medical students from the University of North Dakota School of Medicine and Health Sciences who were trained in the role of scribe and found that it was both a positive experience for physicians and students. 8 Emergency physicians, when compared to junior ED doctors, spend a higher proportion of their time multitasking with 77 min of overlapping activity in each hour, including 42% on communication and 35% on direct clinical care. 9 As ED consultants' time spent on documentation and accessing e-resources is less, 9 the increase in documentation efficiency was perceived to be of most benefit when students are paired with ED doctors completing their training, such as SRMOs and registrars.
In comparison to medical scribes, final year medical students are also uniquely qualified to understand the medical terminology and multiple conditions that patients are often treated for in the ED. 10 Targeted history taking to rule in or out specific diseases in patients may be appreciated more by medical students with adequate clinical acumen and experience. For example, they may have better insight into risk factors for the development of venous thromboembolism such as long-distance travel.
Since 2012, the Independent Hospital Pricing Authority (IHPA) has implemented coding systems in ED to classify diagnoses which align with Australia's activity-based funding system. 11 The IHPA determines the national efficient price and cost each year for healthcare services to inform the funding of public hospitals with Commonwealth funding. 9 This financial model provides funding to hospitals based on the volume and acuity of patients treated and relies on specialised medical record coders who apply codes which effectively equate to a dollar amount. The principal diagnosis, along with up to two additional emergency care diagnoses, are assigned to a patient during their ED stay, allowing for the allocation of appropriate codes and subsequent funding for the hospital. 10 As such, AiMs can apply their medical knowledge and clinical experience to facilitate the addition of multiple relevant diagnoses to clinical documentation and discharge summaries resulting in more billing codes per diagnosis. 5 The use of students as scribes has been shown to improve financial reimbursement as there was a reduction in time required for electronic health record work. 8 There are obvious disadvantages to using medical students rather than scribes, primarily the fact that their time in the ED is short as the nature of their situation is to rotate through different specialities throughout their degree. Medical scribes, while requiring more training initially, will have a more consistent presence and experience in the department. 12 Limitations As a single centre study with a small sample size of eight AiMs, this pilot study is limited in its generalisability to larger centres. The limited duration of the study at 10 weeks means less research data has been collected to analyse and subsequently draw conclusions from. Although 80 shifts were initially rostered between eight AiMs over 10 weeks, only 47 survey responses were obtained because of a combination of sick leave from contracting COVID-19 and incomplete data collection. As the present study did not allocate AiMs to the ED consultants, it is not able to compare the impact of AiMs on the productivity of more senior doctors. Walker et al. found that it was more cost-effective to allocate medical scribes to more efficient doctors such as emergency physicians. 13 The subjective nature of the survey also generates a degree of measurement bias among the doctors completing the survey because of differences in how they perceive and respond to the questions. This also creates difficulty in measuring and analysing the outcomes of the study as there was no objective instrument utilised. Other limitations include acquiescence and social desirability response bias because of the leading nature of survey question phrasing. Without the use of pre-/post-intervention surveys, the results are likely skewed towards positive findings supporting the study aims. Another important component to consider in the present study could have been a survey to assess the AiMs perspectives on their experience in the ED, particularly in comparison to their normal clinical placement to evaluate the perceived clinical and educational benefits. There is a possible opportunity cost involved as although hours worked as an AiM were attributable to clinical placement hours, less time was able to be spent on clinical placements as a medical student.
As previously stated, the employment of final year medical students as AiMs has been trialled since March 2020 as part of the NSW Health COVID-19 medical surge workforce. 2 However, there has been no research conducted in Australia regarding the possible ongoing utilisation of this programme in ED. For future research, a longer duration of study and a larger multicentre sample size would be beneficial to further assess the effectiveness of AiMs. Further analysis of objective comparative measures, such as number of patients 'I think it provided me the most benefit in fast track where there is higher turnover. We saw a run of fairly straight forward patients at the end of the shift which was more useful than the complex ones I think' 'The AiM programme is a great addition to the ED and increases my productivity and is great on-the-job experience for the AiMs. Please keep it happening!' 'No, should shadow more senior doctors a bit' 'Would be a good addition to the department' 'Nothey are usually a helpful addition and it is probably very helpful for their medical training! I would say there is sometimes pressure to teach which can take time but I am happy to do'

Conclusions
The present study demonstrates strong advantages and benefits in continuing the AiM programme in the ED; however, further research on the utilisation of AiMs is required to evaluate the long-term impacts on emergency physician productivity.