Taskforce Report on 4th Year Curriculum

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EDUCATION/SPECIAL CONTRIBUTION

Report of the Task Force on National Fourth Year MedicalStudent Emergency Medicine Curriculum Guide

Task Force on National Fourth

Year Medical Student

Emergency Medicine

Curriculum Guide*:

David E. Manthey, MD, Chair

Wendy C. Coates, MD, Vice-Chair

Douglas S. Ander, MD

Felix K. Ankel, MD

Howard Blumstein, MD

Theodore A. Christopher, MD

James M. Courtney, DO

Glenn C. Hamilton, MD

Eve K. Kaiyala, MDKevin Rodgers, MD

Aaron B. Schneir, MD

Stephen H. Thomas, MD

This manuscript reports recommendations of the national fourth year medical student emergencymedicine curriculum guide task force. This task force was convened by 6 major emergency medicineorganizations to develop a standardized curriculum for fourth year medical students. The structure ofthe curriculum is based on clerkship curricula from other specialties such as internal medicine and

pediatrics. The report contains a historical context, global and targeted needs assessment, goals andobjectives, recommended educational strategies, implementation guidelines, and suggestions on

feedback and evaluation.

0196-0644/$-see front matter

Copyright 2006 by the American College of Emergency Physicians.

doi:10.1016/j.annemergmed.2005.09.002

[Ann Emerg Med. 2006;47:E1-E7.]

INTRODUCTIONIn 1995, the Macy Foundation Report stated: All students

who graduate from medical school should be capable of handlingemergency situations.1 Review of the literature shows that the

Society for Academic Emergency Medicine (SAEM) havedeveloped and published curricula in 1997 and 1998 that couldbe instituted throughout the various years of medical school.2,3 In2002, the Liaison Committee on Medical Education reportspecifically mentioned emergency medicine for the first time,noting that educational opportunities must be available inmultidisciplinary content areas, such as emergency medicine andgeriatrics..4,5 The need for an organized national curriculum iseven more evident because the number of required emergency

medicine clerkships has steadily increased to 35% of medicalschools.

A task force was convened by 6 major emergency medicineorganizations (American Academy of Emergency Medicine,American College of Emergency Physicians, Association ofAcademic Chairs in Emergency Medicine, Council of Residency

Directors, Emergency Medicine Residents Association, andSAEM) in 2003 to develop a standardized curriculum inemergency medicine. This emergency medicine studentcurriculum guide was developed with the purpose of combiningand updating the earlier versions into a single uniformcurriculum. This new curriculum will also address additionalaspects of curricular design, including feedback, evaluation, andimplementation. The most current Liaison Committee onMedical Education requirements for clerkships are incorporatedinto this curriculum. This version identifies areas of medicalstudent education that are either unique to or suitably coveredby emergency physicians to aid medical schools in developing a*All members are listed in the Appendix.

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comprehensive curriculum. The structure of the curriculumwas based on review of curricula of other specialties such asthe Clerkship Directors of Internal Medicine and the Councilof Medical Student EducatorsPediatrics.

The uniformity of a curriculum across medical schoolswould make the education, evaluation, and testing of all

students in emergency medicine more comparable. Thisapproach was designed for fourth year rotations because thesestudents already have basic clinical skills, knowledge, andexperience from the uniform core third year clinical rotations.

Goals and ObjectivesThe emergency medicine curriculum guide objectives specify

student skills and behaviors that are central to care of anemergency department (ED) patient and are appropriatelyevaluated in the context of a fourth year emergency medicinerotation (Table 1). The complexity of the tasks was selected tocorrespond to the abilities of a fourth year student. Theseobjectives are based on previous curricula and Liaison

Committee on Medical Education directives for clerkshipobjectives. Using the Accreditation Council for GraduateMedical Education6 core competencies as a framework, wedeveloped the key learning goals for fourth year studentsenrolled in an emergency medicine rotation. Use of the sameterminology helps ease the transition between undergraduateand graduate education for the student and the educator.

These objectives can be taught and evaluated in varioussettings to include clinical bedside teaching,7-13 standardizedpatients,14-16 observed structured clinical evaluation,17 lectures,problem-based learning groups,18,19 self-directed learningmaterials, and simulations.20-23

Educational CoreIn addition to the objectives of the emergency medicine

rotation, the educational core identifies the basic set of clinicalpresentations, procedures, and educational topics that would becovered or experienced during the clerkship. This core isbased on previously published curricula and consensus opinion.There will be wide variability in how this educational core istaught, reflecting the resources of each program.

Clinical experience. Clinical experience in the ED is thefoundation of all emergency medicine clerkships. The majorportion of the clerkship should involve medical students

Table 1. Core competency-based course objectives.

Core Competency Course Objective

Patient care Obtain an accurate history and physical

examination focused on key problems

Recognize immediate life-threatening

illnesses

Patient management skillsDevelop an evaluation and treatment

plan

Monitor the response to therapeutic

interventions

Make proper disposition and follow-up

plans for the patient

Procedural skills

Learn the indications and

contraindications for basic procedural

skills

Perform basic procedural skills

(Educational Core section)

Health promotion

Discuss preventable injuries and illnesses

Educate patients and insurecomprehension of their outpatient

treatment plan

Medical knowledge Develop the skills to evaluate an

undifferentiated patient

Development of a differential diagnosis

Hierarchy based on the initial patient

presentation

Be aware of worst-case diagnoses

Develop management plan for the

evaluation of the patient

Interpret the results of common

diagnostic procedures and tests

Learn key concepts of

the topics within the educational corePractice-based learning Effectively use available information

technology to solve patient care problems,

improve knowledge base, develop case

presentations

Interpersonal and

communication skills

Humanistic qualities

Effectively communicate patients and

family members

Show compassion and nonjudgmental

approach to all patients

Work in a collegial manner within a

health care team

Presentation skills

Present cases in a complete, concise,

and orderly patternClearly delineate primary problems and

management plan

Complete documentation that is

accurate, well organized, and appropriate

for level of care provided

Professionalism Work ethic

Be conscientious, on time, and

responsible

Exhibit honesty and integrity in patient

care

Practice ethical decisionmaking

Professional behavior

Table 1 (continued).

Core Competency Course Objective

Exercise accountability

Maintain a professional appearance

Be sensitive to culture issues (age,

sex, culture, disability, etc)

System-basedpractice

Make an appropriate referral from the EDUnderstand the role of emergency

medicine in the community, including access

to care and its impact on patient care

Be aware of medication and treatment costs

Fourth Year Medical Student Emergency Medicine Curriculum Guide Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide

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primarily treating patients in the ED under qualifiedsupervision. Because of multiple factors, including theunpredictable nature of emergency medicine, clinical experiencemay be quite variable, even within a clerkship rotation.24

The Liaison Committee on Medical Education hasrecommended that the objectives for clinical education must

include quantified criteria for the types of patients (real orsimulated). needed for the objectives to be met. Certainpresentations of ED patients that are common and to which allfourth year medical students would be uniformly exposedduring their clinical experience based on a national curriculumare listed below.2,25-29

1. Abdominal/pelvic pain2. Alteration/loss of consciousness3. Chest pain4. Fracture5. Gastrointestinal bleeding6. Headache

7. Resuscitation8. Shock9. Shortness of breath

10. Vaginal bleeding11. Wound care

This list is not meant to identify the only types of patients astudent will encounter or negate the importance of many otherpatient presentations. Recognizing the variation in clinicalvenues between various EDs, this task force believes thequantification of the presentations on this list should be left tothe individual institutions.

Procedures. Certain procedures to be taught underappropriate supervision during the emergency medicinerotation are listed below. Procedures were selected based onclinical relevance, level of student training, and availabilitywithin the ED.1. ECG2. Foley catheter placement3. Interpretation of cardiac monitoring4. Nasogastric tube placement5. Peripheral intravenous access6. Pulse oximeter7. Splint application8. Wound closure9. Venipuncture

The procedures listed here are derived from previouscurricula, consensus opinion, and informal evaluation ofprocedures currently performed on rotations. In recognition ofthe variation of what procedures might be available on clinicalshifts, the use of cadaver lab, mannequins, direct observation,videotape presentations, and simulators is encouraged.19-23

Students may have already developed competency in a givenprocedure during an earlier rotation.

Essential topics. Clinical experience cannot provide a studentwith every aspect of the curriculum, nor can one guarantee whatclinical presentations a student will encounter. Therefore, acore knowledge base relevant to emergency medicine topics

should also be taught. This list of essential topics is based onpreviously published curricula, the model curriculum foremergency medicine residencies, and consensus opinion. Thetopics are primarily organized by symptom complex orpresenting complaint and are listed in Table 2.

Although specific diseases are listed, a symptom-oriented

approach to instruction is recommended. The rationale behindthis approach is to emphasize the evaluation and treatment ofpatients with undifferentiated disease processes, which isfundamental to the practice of emergency medicine.30

We suggest that relevant epidemiology, pathophysiology,medical history and physical examination findings, diagnosticand therapeutic interventions, and disposition be addressed foreach symptom complex or disease process.

The various educational venues used to teach these topicsand procedures should ideally be complementary and mayinclude lectures, bedside teaching, self-study materials, medicalstudent-generated presentations, simulated encounters, direct

observation, and laboratory workshops.

31

FeedbackThe Liaison Committee on Medical Education has specified

that each student should be evaluated early enough during a unitof study to allow time for remediation. Feedback is anobjective appraisal of performance that identifies potential areasof improvement so that the student can progress in his or herdevelopment.32 Distinct from evaluation, feedback presentsinformation, not judgment, and is timed to allow for the studentto improve. In the process of giving feedback to students,emergency medicine teachers should be viewed as student allies.33

Identifiable goals and objectives should be given to the studentduring an orientation process at thebeginning of the clerkship andshould serve as the foundation for feedback, formal testing, andevaluation.7,32,34 Feedback, when used to alter an undesirablebehavior, should be given in the form of constructive criticismwith alternative methods of addressing the dilemma. Feedbackshould also be used to reinforce those desirable traits andbehaviors. A resource on feedback with students is available atSAEM Medical Student Educators Handbook, available onlineat http://www.saem.org/download/Hand-4.pdf.

There are 3 ideal times for student feedback. Brieffeedback is spontaneous and occurs at the point of contact.A faculty member may give brief feedback when observing a

student physical examination on a patient or performance ofa procedure or when monitoring a students presentation of apatients medical history and examination in the clinical ordidactic venue.

Formal feedback is provided when a period, usually 5 to10 minutes, is set aside to deliver feedback to the student.Formal feedback may relate to the management of a particularlydifficult or confusing case, to a medical mistake, or to abehavioral issue. Formal feedback is best given at the end of ashift. Ideally, this feedback should be given to students daily.The more frequent the feedback and the closer to the event, themore effective it is for the student. Students should be

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encouraged to ask for specific comments on their performanceand areas to improve at the end of each shift.

Major feedback consists of scheduled sessions midwaythrough the clerkship. These sessions should always be held inprivate and typically last for 15 to 30 minutes. The student knows

ahead of time when his or her major feedback session willoccur and is able to reflect on and assess his or her performancebefore feedback is given. This major feedback session is criticalso that the student can be given areas to work on and remediateduring the remainder of the rotation instead of discovering atthe end of the clerkship that there were deficiencies. It is also anexcellent time to monitor the progress of a students attainmentof an appropriate number of clinical procedures and skills,which may be a condition on which graduation depends.

EvaluationThe Liaison Committee on Medical Education also specifies

that the directors of all courses and clerkships must design andimplement a system of formative and summative evaluationof student achievement in each course and clerkship. Theevaluation of students should be designed to assess theperformance of the student based on the predefined learningobjectives. Core evaluation methods are discussed in currentliterature available to the clerkship directors.35,36

Summative and formative evaluation. Evaluations of studentsshould be structured and contain summative and formativeevaluation processes. Summative evaluation involves makingjudgments about the students concrete achievements during therotation; it is the mechanism by which students are

Table 2. Core educational topics.

Presenting Conditions (Approach to ...)

Approach to ... Specific Disease Entities

Abdominal/

pelvic pain

Aortic aneurysm

Appendicitis

Bowel obstruction

Cholelithiasis/cholecystitisDiverticulitis

Ectopic pregnancy

Ovarian torsion

Nephrolithiasis

Testicular torsion

Alteration/loss of

consciousness

Hypoglycemia

Seizure

Syncope

Chest pain Acute coronary syndromes

Aortic dissection

Pneumothorax

Pulmonary embolism

Environmental

exposures

Burns (chemical, thermal)

Envenomations (hymenoptera, Latrodectus,

Crotalus)Hypothermia/hyperthermia

Eye pain, vision

change

Acute angle closure glaucoma

Trauma

Retinal detachment

Gastrointestinal

bleeding

Upper (peptic ulcer disease, variceal)

Lower (diverticulosis, hemorrhoids,

malignancy)

Headache Mass lesions

Meningitis

Migraine

Subarachnoid hemorrhage

Poisoning/overdose Anion gap metabolic acidosis

Decontamination (activated charcoal)

Specific poisonings/overdoses

Acetaminophen

Carbon monoxide

Opioids

Salicylates

Tricyclic antidepressants

Toxic alcohols (ethylene glycol, methanol)

Psychiatric Psychosis

Substance abuse

Suicidal ideation or attempt

Resuscitation Basic airway management

Basic airway maneuvers

Airway adjuncts

Bag-valve-mask ventilation

First minute of a code

Cardiopulmonary resuscitationDysrhythmia identification/treatment

Shock Anaphylactic

Obstructive (pulmonary embolism, pericardial

tamponade)

Cardiogenic

Hypovolemic

Septic

Shortness of breath Airway obstruction

Asthma/chronic obstructive pulmonary disease

Heart failure

Pneumonia

Pulmonary embolism

Table 2 (continued).

Presenting Conditions (Approach to ...)

Approach to ... Specific Disease Entities

Traumatic injuries Abdomen (bowel, hepatic, splenic injuries)

Chest (hemothorax, pneumothorax, tension

pneumothorax)

ExtremitiesDislocations

Fractures

Splinting

Head injuries (epi-/subdural hematomas)

Neck/spine (cervical spine fractures, spinal

cord damage)

Pediatric nonaccidental trauma/domestic

violence

Vaginal bleeding Abortion (threatened/ complete/incomplete/

inevitable)

Ectopic pregnancy

Placenta previa

Placental abruption

Weakness and

dizziness

Cerebrovascular accident (embolic,

hemorrhagic, thrombotic)Vertigo (benign positional vertigo, cerebellar

hemorrhage)

Wound care Irrigation

Local anesthesia

Primary closure

Tetanus prophylaxis




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accountable for what they have learned during the rotation.Summative evaluation is primarily a retrospective process inwhich students accomplishments and habits are documented.

Formative evaluation focuses on identifying studentstrengths (for subsequent amplification) and weaknesses (forremediation). Formative evaluation is primarily a prospective

process in which students strong and weak points are assessedwith an eye toward improvement in future evaluations.Optimally applied, formative evaluation helps students developgood habits. Many types of formative evaluation can also beused as aids for summative evaluation, and vice versa. Forexample, testing can be used, at least in part, for both typesof evaluation.

The final evaluation is summative but may include formativecomments. The summative evaluation should clearly definethe students abilities with respect to the identified objectivesbased on their performance during the rotation. Anyimprovements made during the clerkship, especially on those

items identified at the major feedback session, should benoted. The formative evaluation should provide the studentswith their strengths, areas of improvement, examples ofdeficiencies, and a plan for improvement.

Types of EvaluationAlthough there are many types of evaluations, each with its

own values, we outline evaluations that are practical for allrotations. Evaluation techniques beyond these are encouragedbased on the abilities and resources of the rotation.

Direct observation. Direct observation of a student duringhistory taking, physical examination, or procedures in theclinical setting allows evaluation of a students ability based onprespecified performance-based criteria.37-39 Interpatientvariability in clinical problems and a patients ability to beinterviewed are 2 potential confounders to this method ofevaluation. Resources available include the evaluation chapter inthe SAEM Medical Student Educators Handbook, availableonline at http://www.saem.org/download/Hand-2.pdf.

Shift evaluation. Ideally, an evaluation in the clinicalsetting can be done after every shift, if it is feasible.40

Evaluation of the students history and physical andpresentation techniques may occur during the oral presentation.With direct questioning, additional information on thestudents ability of investigatory thinking, application of basic

science knowledge, and the use of evidence-based medicineto solve clinical problems may be evaluated. The student mayalso be evaluated on his or her ability to define differentialdiagnoses and develop treatment and evaluation plans.Professionalism and the ability to communicate duringinteractions with family, consultants, and coworkers can all beassessed during this time.41

Examinations. Examinations (written or oral) can beincorporated into the evaluation of the students knowledgebase and should correlate with the educational core topics.A national testing database would aid educators in developinga practice and final test. Ideally, the examination should be

studied by various statistical tests to ensure the test questionsreliability, level of difficulty, and discriminatory power.

Objective testing must be supplemented by other evaluationmechanisms, and the students should understand that theeducational goal is not short term retention of factualknowledge. An examination should be used as part of a system

that fosters self-initiated learning by the student.Procedural evaluations. Evaluation of procedural skills can

be measured against a checklist of essential actions duringdirect observation of clinical work or during proceduralworkshops. Although students should keep logbooks ofprocedures performed, these are insufficient to evaluate thetechnique of the student.

Format of final evaluation. The format of the final evaluationis most often determined institutionally. However, in line withLiaison Committee on Medical Education requirements, theevaluation must include narrative descriptions of studentperformance, including noncognitive achievements.5 This

evaluation should be based on faculty-student interactionsduring the course.Evaluation of the faculty and clerkship. All students

completing the emergency medicine clerkship must have theopportunity to give feedback about their educational experience,including individual faculty and the educational program.5

Students will feel most comfortable providing anonymousfeedback about their teachers and the clerkship at the end of therotation. Results may be useful for individual facultydevelopment and promotion, for identification of institutionalproblems, and to provide evidence for resource allocation fromthe medical school.

Implementation planRecognizing that resources and constraints vary by individual

institution, this curriculum is sufficiently broad based to allowfor individualization that conforms to the goals and resources ofthe medical school and specific clerkship. It is suggested thateach clerkship director have the ability to mold the curriculumto the strengths of the department and desires of the medicalschool while remaining within a common framework thatallows for a uniform education of medical students in ourspecialty. The following are based on available literature whenpossible but also reflect the experience of the authors asclerkship directors.

Prerequisites for clinical sites.42 Theclerkship directorshould beavailable to receive feedback from medical students for correctingany identified inadequacies. The clerkship director would alsoprovide a summary evaluation at the end of the rotation. Ideally,there would be an identified site director at each clinical location,responsible for overseeing the education and well-being of thestudents. The site director or clerkship director would ensure thatscheduling of student shifts conforms to standard duty hours ifrequired by the individual medical school.

Other desirable institutional features of a clinical site includehaving adequate, up-to-date equipment, including computer orlibrary resources, as well as ensuring a safe environment.


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Faculty members at a clinical site should be board certifiedor residency trained in emergency medicine and should befamiliar with the course objectives. Faculty members should bewilling to make a consistent commitment to provide teaching andformative evaluation during each shift. The faculty should bededicated to making certain that the student enjoys a broad-based

clinical experience that focuses on education, not service.43,44

Clinical experience. It is essential that the clerkship provide anadequate clinical experience.45 The student should have theopportunity to be involved with the aforementioned patientpresentations and procedures under faculty or upper-year-resident supervision. Clerkship and site directors should use logsto monitor the students experiences to include chief complaint,final diagnosis, and procedures.

Based on these logs and required clinical experiences, theclerkship may consider using scripted patient scenarios, highfidelity simulation laboratories, and procedural models tosupplement clinical contact.

Didactic experience. Didactic opportunities should besubstantially similar at all sites. Goals and objectives, as well asthe educational core, should be maintained by the coursedirector and disseminated to site directors and faculty.Optimally, didactic opportunities should be offered by qualifiedemergency medicine faculty or by emergency medicine residentswith adequate supervision. Course directors may wish to holddidactic opportunities at a single, central site in order to ensureconsistency of learning opportunities among students.

Regular feedback from students should be sought by thecourse director and reviewed to ensure quality. The coursedirector should provide feedback to faculty and the academicchair about opportunities for improvement.

Future directionsA cohesive network of educators can be formed to provide

continuous quality improvement of this document and theeducation of medical students within the specialty of emergencymedicine. A repository of educational innovations can bedeveloped and shared among programs. Evaluation instrumentsshould be developed and implemented that will help educatorsin assess competency within the recommended curriculum.A national test can be developed based on the uniformity ofthe educational curriculum among various clerkships.

ConclusionA collaboration of medical education experts from the

major emergency medicine organizations has produced thisemergency medicine curriculum guide that proposes uniformstandards for the enrichment and advancement of theeducation of medical students. This document has beenendorsed by all 6 of the participating emergency medicineorganizations. It should prove useful to clerkship directors,emergency medicine faculty, and medical education deans toplan or redesign a comprehensive program in emergencymedicine that addresses goals and objectives, core educationaltopics, and feedback and evaluation.

Supervising editor: Donald M. Yealy, MD

Funding and support: The American College of Emergency

Physicians provided $300 for copyediting services. There is no

financial interest of the authors in this product. The authors

report this study did not receive any outside funding or support.

Publication dates: Received for publication May 12, 2005.Revision received August 31, 2005. Accepted for publication

September 2, 2005.

Address for reprints: David E. Manthey, MD, Department of

Emergency Medicine, 4th Floor Watlington Hall, Wake Forest

University School of Medicine, Medical Center Boulevard,

Winston-Salem, NC 27157-1089; 336-716-4629, fax 336-716-

5438; E-mail [email protected].

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Appendix. Task Force on National Fourth Year Medical Student

Emergency Medicine Curriculum Guide

David E. Manthey, MD, Chair, and Howard Blumstein,MD, Department of Emergency Medicine, Wake ForestUniversity School of Medicine, Winston-Salem, NC; Wendy C.Coates, MD, Department of Emergency Medicine, HarborUCLA Medical Center, Torrance, CA; Douglas S. Ander, MD,Department of Emergency Medicine, Emory University Schoolof Medicine, Atlanta, GA; Felix K. Ankel, MD, Department of

Emergency Medicine, Regions Hospital, EmergencyDepartment, St. Paul, MN; Theodore A. Christopher, MD,Department of Emergency Medicine, Thomas JeffersonUniversity Hospital, Philadelphia, PA; James M. Courtney,DO, Department of Emergency Medicine, University ofMassachusetts Medical Center, Worcester, MA; Glenn C.Hamilton, MD, Department of Emergency Medicine, CoxHeart Institute, Kettering, OH; Eve K. Kaiyala, MD,Department of Emergency Medicine, Valley Medical Center,Renton, WA; Kevin Rodgers, MD, Department of EmergencyMedicine, Indiana University, Indianapolis, IN; Aaron B.Schneir, MD, Department of Emergency Medicine, UCSDMedical Center, San Diego, CA; Stephen H. Thomas, MD,Department of Emergency Medicine, Massachusetts GeneralHospital, Boston, MA.

These members represented the following organizations:American Academy of Emergency Medicine, American

College of Emergency Physicians, Association of AcademicChairs in Emergency Medicine, Council of ResidencyDirectorsEmergency Medicine, Emergency MedicineResidents Association, and the Society of Academic EmergencyMedicine.

The task force received letters of endorsement from all 6 ofthe organizations.


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Taskforce Report on 4th Year Curriculum

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