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, 21,22,23]. 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.
Limitations
There was no specific defined number of patients or procedures that are required to be achieved by students in the literature. Terminology in the current EM clerkship guidelines are not specific for logging the presentations [9]. We have to acknowledge that our study has certain limitations. Because of the hardcopy logbook format used in our study, we were not able to analyse more than one complaint of the patients. This underestimated the full exposure of students. Furthermore, supervisors accepted, modified or cancelled the students’ patients or procedures in the logbook according to their judgement. There is a potential categorisation error in this process. However, the supervisors, preceptors and Clerkship Director did their best to assure the validity of our data. Manual data entry may have errors and high-stress shifts may reduce direct supervision of students. It is useful to know whether there is a relationship between the range of presentations encountered by the students and the case mix for each ED. This will provide some insight as to whether a presentation is uncommon for a specific ED or simply a lack of opportunity for students to encounter these presentations despite being relatively common. We had no full data on location, unit, time, and date of encounters. Accordingly we could not analyse this relationship. We have recently developed a new electronic logbook to address this point.
Although students received a one-hour orientation covering how to fill their logbook, students’ decision making for log entries varied, because of variations in symptoms, patients, students, supervisors, and possible multiple complaints in the patients. Our process cannot guarantee that all students act identically when entering presentations. Other authors have indicated that although students should follow the structure and guidance provided by log books this should not be a substitute for a meaningful clinical supervision. Logbooks should be a tool that highlights the importance of quality rather than quantity of patient interactions [25]’.
We also acknowledge that exposure to these patients alone does not assure learning. However, teaching and learning is a holistic body affected by multiple factors. Although we have applied various curriculum delivery modes to achieve the learning outcomes of our students, we cannot completely guarantee that the students met all the desired learning outcomes of the course. There is also a possibility that students enetered data into the logbook depending on their interests or needs which is characteristic of adult learning. This might affect the accuracy of reporting. Finally, the study includes a single medical college and 1 year period. Therefore, the generalization of the results may not reflect the reality in a different setting. However, our results were similar to other studies from different parts of the world, which shows limited exposure during the clerkship.
