Do senior medical students meet recommended emergency medicine curricula requirements?

Emergency Medicine (EM) is an important medical field requiring proper training which is critical for accreditation of medical education programs [1]. Therefore, application of well-established EM curricula in medical schools is vital. EM curriculum development started in the mid-1980s [2, 3]. This curriculum was developed during the last 25 years and implemented in many medical schools. The American College of Emergency Physicians (ACEP), the Society for Academic Emergency Medicine and International Federation for Emergency Medicine are the three main associations which work on the development of medical school curricula [3, 4]. The last curriculum was published in 2010 by the Clerkship Directors Group of Emergency Medicine (CDEM) of Society For Academic Emergency Medicine [5]. Similar presentations and procedures for curriculum were also reported in a different setting by Penciner et al. [6].

Students need a healthy and rich educational environment to improve their skills. Being able to achieve learning objectives is one of the main driving forces for a successful clerkship [7]. Exposure to patients including quantity and severity vary between different settings. Hem-Stokroos et al. showed that individual students’ exposure to various patient problems during a 10-week surgical clerkship was insufficient. The students were not exposed to sufficient quantities of emergency patients [8]. Emergency departments offer rich learning opportunities for undergraduate students because of the variety of acute presentations, significant number of patients, and different emergency procedures. Although a list of clinical presentations has been suggested by the current curriculum [5], a recent study concluded that most students do not encounter all recommended ten emergency presentations [9]. Without identifying the clinical activities that students are experiencing, it is difficult to evaluate whether they are receiving proper training during their EM clerkship [10]. Do our senior medical students meet the recommended curriculum requirements during their rotation? Do they encounter substantial numbers of core presentations and procedures? Answers to these questions are unknown in many EM clerkships. Application of a recommended curriculum in different settings helps to evaluate its applicability and generalizability. Finding similarities or gaps in different settings provides feedback for users and developers of the curricula. We aimed in this study to evaluate the clinical exposure of final year medical students at our college during their EM clerkship.

Five thousand one hundred twenty-two patient presentations, and 3246 procedures were recorded in the logbooks of all students. An average (SD) of 68.3 (17.6) patients and 46.1 (14.0) procedures. The mean age (SD) of patients was 34.2 (23.4) years. None of the students encountered all recommended presentations by CDEM curriculum (10 presentations). 24 students (32%) encountered between 7 and 9 of CDEM recommended presentations, and 4 students (5.3%) logged 9 presentations.

Our study has shown that final year medical students encountered less patient presentations and procedures than those recommended by our clerkship curriculum. Abdominal pain, chest pain, and respiratory distress were the highest achieved presentations. Intravenous line placement, ECG application and interpretation, and suturing were the highest achieved procedures.

Emergency departments provide a wide range of presentations and procedures for trainees to encounter, observe and participate in. Clinical activities during shifts are useful educational tools for the EM clerkship [11]. Clinical logbooks are valid to document these activities [12] as they increase student attention to perform medical procedures [13]. It is important to define the learning opportunities so as to improve teaching and learning activities. We can then modify the curriculum depending on each local setting [10].

Avegno et al. reported that about 15% of students examined all recommended presentations of the CDEM curriculum during their EM clerkship [9]. Our findings were similar in common presentations including abdominal and chest pain. Furthermore, their least encounters were shock and cardiac arrest which is similar in our context. Conversely, abdominal and chest pain were seen by 100% of students in the aforementioned study which was also similar to our findings. Cardiac arrest was the only presentation encountered in less than 70% by their students. In our study, this occurred in six presentations. Similar to our findings, McGraw and Lord found that abdominal pain was the most frequent encountered presentation, however, there were no encountered cardiac arrest patients in their study [10].

Suturing was the most commonly performed procedure by students as reported by McGraw and Lord [10], whereas suturing was the third highest encountered procedure in our study. McGraw and Lord showed that students performed an average of one intravenous line insertion [10] compared with 16 in our study. Cardiopulmonary resuscitation was not encountered in their study, and this was also low in our setting. This can be explained by the young age of our population. Nearly 50% of students did not encounter urinary catheterization in McGraw and Lord’s study which is similar to ours [10]. The large number of trainees in Tawam-John Hopkins and Al Ain Hospitals may affect students’ hands-on training. Students may be competing with other residents and trainees in different activities. In addition, some procedures such as urinary catheterization are performed by nurses and their students.

ACEP’s curriculum included 16 knowledge categories such as emergency medical services, cardiovascular diseases, and trauma. There were also specific categories such as ophthalmologic emergencies. There were 15 procedures in the list including basic emergency procedures (gastric lavage, tetanus prophylaxis etc.) as well as cricothyroidotomy and pericardiocentesis. Although emergency departments can provide more exposure than other rotations [14], only about 20% of the ACEP curriculum recommendations could be seen by 80% or more students [15]. In our study, only 5 out of 10 presentations and 2 out of 9 procedure categories, which were recommended by CDEM, were achieved by more than 80% of our students. In the literature, none could achieve 100% completion of all 10 recommended presentations [16, 17]. Nevertheless, setting high standards is useful because it helps us to improve our performance in the clerkship. Furthermore, there are institutional and specialty differences with regard to patient numbers, conditions and achievement level of students [9, 18]. The breadth of clinical experience during an EM clerkship is context specific and dependent on a variety of factors, including case mix and acuity of patient presentations. It is therefore expected to find similarities and differences in the range of presentations and procedures encountered in our study compared with previously published studies.

Medical students show confidence in acute care knowledge, disease management, and procedural skills after completion of an EM clerkship [19]. However, there is no clear description of the level and amount of student involvement during an EM clerkships.

We have added EFAST and rapid ultrasound in shock and hypotension (RUSH) protocols to be achieved by students. Ultrasound training is highly recommended for undergraduate medical education [20]. Our students have been exposed to EFAST and RUSH protocols training since 2013. They are encouraged to use these techniques during clinical shifts. Unsurprisingly, EFAST was encountered in over 80% by of our students while RUSH protocol was encountered by less than 65%.

A strength of this study is its facilitation of recognition of deficient curricular areas needing to be addressed. Our results should nevertheless provide some reassurance to clerkship directors and curriculum developers that the clerkship is providing some very useful opportunities for emergency care encounters. This is particularly important since emergency medicine is being increasingly recognized as an important learning experience for medical students. Furthermore, this conclusion extends across two different EM settings with different patient populations. Low encountered presentations and procedures should be emphasized more in a variety of teaching sessions including simulations [11, 21–23]. Another important finding of our study is that majority of the logged presentations, and 19% of logged procedures were under the ‘other’ category which describes students’ exposure to the presentations and procedures other than the recommended curriculum. Timely feedback to students may guide them in fulfilling the required clerkship objectives. Hard copy logbooks are not useful in giving timely feedback to students. Penciner et al. reported that electronic logging by medical students during an EM clerkship has many advantages [24]. The present study highlights the need for creating an electronic logbook which can regularly check student activities on a daily basis and give continuous feedback.

Recommended presentations and procedures of the EM clerkship were not fully encountered by all of our students. Different settings vary in the available type of patients and procedures. Each clinical clerkship should tailor their teaching methods according to the available clinical learning opportunities. EM Clerkship Directors should monitor their students and their clinical environment targeting to achieve the objectives of their educational curriculum.