How to Run an Emergency

Medicine Residency Program

Jim Holliman, M.D., F.A.C.E.P.Professor of Military and Emergency MedicineUniformed Services UniversityClinical Professor of Emergency MedicineGeorge Washington UniversityBethesda, Maryland, U.S.A.

My Background for This Lecture

• Program Director for proposed Penn State University E.M. Residency and wrote the Program Information Form for this in 1991

• Helped develop Joint E.M. Residency Program (York Hospital – Penn State Hershey) and served as Associate Director of this 1994 – 2003

• Associate Director of the independent Penn State Hershey E.M. Program 2004 – 2007

• C.O.R.D. member 1994 - 2007

General Benefits of Having Specialty Residency Training in Emergency Medicine (E.M.)

Provides core of specialists to staff emergency departments (E.D.'s).

Provides physician leadership :–E.D. administrators or managers–Prehospital care system directors–Coordinate outpatient & inpatient care

Ensures quality, depth, and uniformity of training for emergency care.

Teaching E.M. residents can provide a lot of career satisfaction, and can be fun !

Essential Ingredients for a Successful E.M. Residency Program

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• An enthusiastic, energetic, career-dedicated, knowledgeable, and clinically competent Program Director

• A cooperative and supportive Department Director and Core Faculty

• An energetic and supportive Program Coordinator

• Support from the hospital administrators and other clinical departments

Start-Up Sequence for a New E.M. Residency Program

• Obtain institutional support and initial financing.• Find and hire an experienced Program Director.• Put in place all the structural components (see the

Accreditation Council for Graduate Medical Education web site www.acgme.org for the “Common Program Requirements” and the Residency Review Committee for E.M. Specific Program Requirements).

• Fill out and submit the Program Information Form (PIF) to the ACGME.

• Be nice to the Residency Review Committee representatives when they arrive to inspect the proposed program.

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1. There must be a single program director with authority and accountability for theoperation of the program. The sponsoring institution’s GMEC must approve achange in program director. After approval, the program director must submit thischange to the ACGME via the ADS.[As further specified by the Review Committee]2. The program director should continue in his or her position for a length of timeadequate to maintain continuity of leadership and program stability.3. Qualifications of the program director must include:a) requisite specialty expertise and documented educational and administrativeexperience acceptable to the Review Committee;b) current certification in the specialty by the American Board of ________, orspecialty qualifications that are judged to be acceptable by the ReviewCommittee; and,c) current medical licensure and appropriate medical staff appointment.[As further specified by the Review Committee]4. The program director must administer and maintain an educational environmentconducive to educating the residents in each of the ACGME competency areas. Theprogram director must:a) oversee and ensure the quality of didactic and clinical education in allinstitutions that participate in the program;b) approve a local director at each participating institution who is accountablefor resident education;c) approve the selection of program faculty as appropriate;d) evaluate program faculty and approve the continued participation of programfaculty based on evaluation;e) monitor resident supervision at all participating institutions;f) prepare and submit all information required and requested by the ACGME,

Sample Text Lifted from the ACGME Web Site Document “Common Program Requirements” (an 81 page document)

Assistive Resources in Starting a New E.M. Residency

• The Society for Academic E.M. (S.A.E.M.) has a Residency Consultation Service (for a fee the Service will send an experienced reviewer to analyze the proposed program and its PIF).

• The Council of Residency Directors (C.O.R.D.) has helpful information on its web site (www.cordem.org) and at its several meetings each year (the Program Director(s) should be a member).

• S.A.E.M. (www.saem.org) and A.C.E.P. (www.acep.org) and E.M.R.A. (www.emra.org) also have good reference information.

General E.M. Residency Program Requirements

• Program must be at least 36 months in duration (can be PGY 1,2,3 or PGY 2,3,4 or PGY 1,2,3,4 formats).

• Should teach the skills, knowledge, and behaviors of E.M. practice.

• At residency completion, graduates should be able to practice E.M., add new skills and knowledge, and monitor their own well being.

Faculty Requirements for U.S. E.M. Residency Programs

Department chief must have :–E.M. board certification, administrative & clinical E.M. experience, academic achievement, involvement in medical organizations, same authority as other institutional chiefs.

Program Director must have :–E.M. board certification, > 3 years experience, be clinically active, be scholarly active, and have at least 50 % “protected time” to run the residency, & full authority over the program.

Teaching Faculty must have :–At least one per every 3 residents, 25 % of time protected for academic activities, some must do research, most must be E.M. board certified, must provide 24 hour a day E.D. coverage, and there must be a faculty development program.

Facility Requirements for U.S. E.M. Residency Programs

Patient census > 30,000 (total) per year.Pediatric census 15 % or 4 months full time equivalent.Critically ill / injured patients : at least 3 % of census or > 1000 per year.

At least 2000 patient encounters per resident per year.Accredited medicine & surgery residencies must be at same clinical site.

Must have offices and program support space for faculty & residents.

Stat lab results should be available in < 1 hour.Must have at least 5 hours per week didactic instruction by faculty.

Requirements for E.M. Residency Sponsoring Institutions

• Medical school affiliation desirable

• Sponsors must be committed to graduate medical education

• Long term financial commitment to the program is needed

• Affiliation agreement needed for each hospital where residents rotate

Additional E.M. Residency Sponsoring Institutions Requirements

• One hospital must be primary ; the Program Director must be based here.

• Reasons to include multiple hospitals should be clear.

• Multiple hospitals should not be geographically distant.

• Residents must participate in conferences even when at different hospitals.

• One faculty must be responsible for resident activities in each institution.

Requirements for Residents in U.S. E.M. Training Programs

May not work > 12 hours continuously in E.D.May not have more than 60 hours per week total clinical timeMay not work > 72 hours per week including on-call & conferencesMust have at least one day off in every 7 daysMust be relieved of clinical duties sufficient to attend at least 70 % of scheduled conferences

> 50 % of rotations & clinical time must be in E.D.Must keep a procedure logbookMust have followup information on admitted patientsMay not be supervised by resident physicians from specialties other than E.M. when in the E.D.

General Structure of U.S. E.M. Residency Programs (cont.)

> 50 % of time (> 18 months) in program must be in the E.D.

Important "off-service" rotations :–Critical care units (pediatric, medical, surgical) : at least two months required–Trauma surgery–Pediatrics–Orthopedics–Anesthesia–Medicine / cardiology

Non-E.D. E.M. Rotations Usually Included in E.M. Residency Programs

ToxicologyPre-hospital careAeromedical care (flying usually optional for residents)

Research1 to 2 months of electives

E.M. Residency Program Director Responsibilities

• Develop goals of program in writing• Select new residents• Participate in faculty evaluation• Ensure appropriate resident supervision• Regularly evaluate the residents in writing• Handle resident grievances• Manage resident stress and wellness• Make sure the program continues to meet the

ACGME RRC-EM requirements

E.M. Residency Educational Program Requirements

• Conferences for residents– At least 5 hours weekly of planned

conference developed by the EM program– Should include : curriculum, Morbidity and

Mortality, journal review, administrative seminars, and research methods

– Faculty should attend conferences also

E.M. Residency Educational Program Requirements (cont.)

• Research and scholarly activity– Journal clubs and research conferences– Professional and scientific meetings– Participate in research or scholarly activity• Most programs require completion of a research

project and an “educational” project

– Learn basic research methodology

E.M. Residency Educational Program Requirements (cont.)

• Resident physician Wellness– One of the main Program Director

responsibilities– Balance personal and professional activities– Provide support for stress, circadian

rhythms, and substance abuse problems– Residents must be pre-notified as to how to

access support services

Helpful Specific E.M. Faculty Roles to Consider

• Assistant or Associate Program Directors (obviously at least one designee is needed to run the Program when the Director is not present ; Programs with more than 18 residents often utilize one Assistant or Associate per each additional 8 to 10 residents).

• Medical Student Rotation Director.

• Director for “Off-Service” residents in the E.D.

Additional Helpful E.M. Faculty Role Assignments to Consider• Research Director• Didactic Conference Series Director• E.M.S. Director• Quality Improvement Programs Director• Official Liaisons to other clinical

departments• Assigning each resident to a Core Faculty

person to act as the primary “counselor” for each resident

Additional E.M. Department Choices to Consider

• Should involve conjoint decision by the Dept. Director and the Program Director :–Medical student rotation(s) in the E.D.– “Off-Service” resident rotations in the E.D.– Having additional “Combined” residencies

(i.e., E.M.-I.M., E.M.-Peds, etc.)– Having postgraduate fellowship(s) ( see next

slide)

Choices for E.M. Fellowship Training Programs (following E.M. residency)

Emergency Medical Services (Prehospital care) : 1 to 2 yearsToxicology : 2 years (separate subspecialty certification)Pediatric E.M. : 2 yearsE.M. Research : 1 to 2 yearsE.M. Administration : 1 yearE.M. Education : 1 yearHyperbaric Medicine : 1 yearSports Medicine : 1 to 2 yearsCritical Care (Intensive Care) Medicine : 1 to 2 yearsAeromedical Care : 1 yearInternational E.M. : 1 to 2 years (may include obtaining an M.P.H. degree) Dedicated E.M. faculty director(s) needed

for any of these

E.M. Program Director Options for Interviewing Resident Candidates

• ? Who performs initial application screening to decide on interview invitations

• ? Use limited number of faculty to do interviews or all faculty as available– ? Have E.M. residents also interview

• ? Have interviews on “E.M. conference day” or other days

• ? Conduct the initial interview(s) in “blinded” mode• ? What type of rank scoring system to use

Suggested Rank Order of Items to Consider in Ranking

E.M. Residency Applicants• 4th year E.M. clinical rotation(s) grade(s)

• Other clinical rotations grades

• Letters of recommendation

• Interview

• Personal statement

• Board scores

• Preclinical course grades

Use of a combined numerical scoring system rating each of these items, with additional point scores for research or other unusual items, has proved useful for many Programs

The Extremely Important Position of E.M. Residency Program

Coordinator

• The “right hand person” for the Program Director

• Success of the residency may depend almost as much on this person as on the Program Director

• Responsible for office components of the Program, to include :– Resident candidate interviewing– Resident, faculty, and Program evaluations– Resident procedure lists and test results files

The Six General Competencies the American Board of Medical Specialties Has Tasked All Specialties to Evaluate

ƒ Patient careƒ Medical knowledgeƒ Practice-based learning &

improvementƒ Interpersonal & communication

skillsƒ Professionalismƒ Systems-based practice

So the Evaluation(s) of residents’ and students’ clinical performance should be linked to these 6 items

Example July Orientation for E.M. R1’s in the Penn State Hershey Program

• 10 E.D. shifts• 25 hours of didactics• 26 hours of lab experience– Live animal procedure lab– Casting lab– Mannequin Simulation Labs – Ultrasound course– Slit lamp lab– Epistaxis control lab

• Life Lion Helicopter Fly - Along 1 to 2 days• “Nurse for a Day” in the E.D.

Education / Scholastic Endeavour Requirements of the Penn State

Hershey E.M. Program

• Project required for graduation– Original Research or Evidence Based

Medicine review– Presented at research conference in June

• Supervised by predesignated faculty

• Presentations at regional or national conferences departmentally funded

Sample Rotation Schedule for the Penn State Hershey E.M. Program

EM-1 EM-2 EM-3

4 mo. EM 6 mo. EM 4½ mo. EM

Anesthesia 2 mo. Community ED (HH) 1½ mo. Administrative EM

Internal Medicine SICU 2 mo. Community ED (HH)

Cardiology Toxicology (HH) Trauma / General Surgery

MICU EMS PICU

Ob-Gyn (HH) Orthopedics Selective

Trauma / General Surgery Elective

Pediatric Surgery

Pediatrics

(HH = “Harrisburg Hospital”, an affiliated local hospital)

Sample E.M. Resident Work Schedule in the Penn State Program

• 9 hour shifts (overlapping with next shift starting at hour 8)

• EM-1 : 23 shifts (48 hours / week)EM-2 : 22 shifts (46 hours / week)EM-3 : 21 shifts (44 hours / week)

• 4 months with call intern year2 months with call 2nd year2 months with call 3rd year

Sample Evaluation Scheme Used in the Penn State Program

• Annual review with Program Director• Quarterly meeting with faculty advisor– Quarterly emergency faculty consensus evaluations– Off-service evaluations– Direct observation forms– Chart reviews– Procedure logs– Follow-up logs– Quiz scores– Research project progress

The American Board of E.M. (A.B.E.M.) In-Training Exam

ƒ Given once per year (February) to all E.M. residents at their residency site

ƒ Similar in length and content to the A.B.E.M. certification exam

ƒ Helps prepare residents for the certification exam

ƒ Allows Program Directors to identify areas of knowledge deficit in their residents which may then alter the residency curriculum, and allows comparison to other residencies

Benefits of Training Other Specialty Residents in E.M.

Allows ability & confidence in managing basic emergencies.

Familiarizes them with E.D. operations and needs.Improves working relationship with E.M. faculty & E.M. residents.

Allows them to learn cost-effective use of ancillary tests.

Provides an educational service to their “home” departments (can be considered “educational payback” for their departments having E.M. residents on their inpatient rotations).

General Recommended E.M. Training for Residents from Other Specialties

Internal Medicine, Family Practice :–1 month in 1st year, 1 month in 2nd or 3rd year

General or Orthopedic Surgery, Anesthesia, Otolaryngology :–1 month in first year

Obstetrics & Gynecology , Pediatrics :–1 month in 2nd or 3rd year

Radiology, Pathology, Psychiatry, Ophthalmology :–May NOT need an E.M. rotation

Considerations for an International Clinical Rotation for the E.M.

Residents• Resident work time for international rotations

is not paid to the Program by Medicare

• Does meet the goals of the six Core Competencies

• Best reference list of rotations is on the A.C.E.P. International E.M. Section sub-web site ; E.M.R.A. is also accumulating a new list

• Shown to be an attractive feature for residencies with applicants

Career Options for E.M. Residents Graduating from U.S. Programs

Private practice–Single hospital physician group–Multi-hospital physician group

Academic practice–Mix of clinical work, teaching, research–Focus on research

Administration–E.D. director–Prehospital system director

Additional fellowship trainingLocum tenens work

Program Directors should be able to prepare their residents for any of these

How to Run an E.M. Residency Program : Summary

• The most important ingredient for a successful residency is an enthusiastic, dedicated, and knowledgeable Program Director assisted by an energetic Program Coordinator.

• Successful E.M. residency operation depends on monitoring and maintaining high quality in each of the many structural and human components of the residency.