This chapter was reproduced from the Emergency Medicine Clerkship Primer, 2008, Chapter 23, with the permission of the Editor, for ease of viewing on mobile devices.
In keeping with its mission to ensure and improve the quality of gradu-ate medical education, the ACGME Outcomes Project Advisory Committee has identified six general competencies for residents. These six competencies were endorsed by the ACGME in February 1999. The six core competencies are as follows:
- Patient care
- Medical knowledge
- Systems-based practice
- Practice-based learning and improvement
- Interpersonal and communication skills
As of 2002, all graduate medical education training programs accredited by the ACGME are responsible for requirements related to the competencies. In the past, residency training emphasized structure and process components. This emphasis will become less critical over time as more emphasis is placed on outcome measures. Graduate medical education training programs are now expected to show evidence of how they use educational outcomes to improve individual resident and overall program performance.
|Graduate medical education training programs are now expected to show evidence of how they use educational outcomes to improve individual resident and overall program performance|
The recently published National Fourth Year Medical Student Emergency Medicine Curriculum Guide emphasizes the use of these six core competencies as a framework for the learning objectives of an undergraduate emergency medicine curriculum. These competencies were selected for two reasons. First, they clearly outline the knowledge, skills, and attitudes that should be instilled in a physician in training. Second, they allow the evaluation of students and residents to be consistent and uniform and ease the transition between medical school and residency. This section of the Primer will review each of the six core competencies and highlight those that pertain to the undergraduate curriculum. An in-depth review of each of the six competencies as they relate to the specialty of emer-gency medicine, specifically residency training, can be found in the journal Academic Emergency Medicine (Acad Emerg Med. 2002;9:1211–1277). Many aspects of the core competencies can be applied at the medical student level, especially during a fourth-year clerkship.
Patient care as defined by ACGME should be “timely, effective, appropriate, and compassionate for the management of health problems and the promotion of health.” To do this, the student must be able to obtain an accurate history and perform a physical examination concisely focused on the patient’s complaint. In the emergency department, the student should be able to identify correctly and immediately any life-threatening illnesses. Patient management skills should include the ability to develop an appropriate evaluation and treatment plan. The student should monitor the patient for response to the outlined therapy and alter this therapy as indicated. The student should also follow through on patient care to include proper disposition and follow-up care when the patient is discharged from the emergency department.
Within the confines of procedural competence, students should be able to list the indications and contraindications of basic procedures they may perform in the emergency department. The basic procedures listed in the National Curriculum include ECG procurement and interpreta-tion, Foley catheter placement, interpretation of cardiac monitoring, NGT insertion, peripheral IV access, pulse oximeter reading, splint application, wound closure, and venipuncture.
Under the auspices of health promotion, the student should discuss any preventable illness or injury as the case presents itself in the evaluation of a patient. This would include items such as smoking cessation, seat-belt and helmet use, and medication compliance. Many of these topics are addressed in detail in the Primer section on anticipatory guidance. The student should educate the patients to the extent that they can un-derstand and assist in implementation of their outpatient care plans. Students should also ensure that patients understand their discharge instructions, can arrange for follow-up care, can afford as well as comprehend how to use medications, and understand when to return for further evaluation.
Other aspects of the patient care core competency as defined by the ACGME that were not abstracted into the medical student curriculum include making informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment. Although mastery may be beyond the scope of experience and knowledge of the student, it certainly should be taught by the instructor and is a critical skill to begin developing. The use of information technology to support patient care decisions and patient education is particularly important and will become an increasingly important part of patient care as the student progresses through residency training and beyond. Any opportunity for the student to use available educational resources to make an informed decision about diagnostic studies or therapeutic intervention is an opportunity to develop and refine this skill and certainly is to be encouraged. Although residents are expected to perform competently all medical and invasive procedures considered essential for the area of practice, students often have limited procedural opportunities before their emergency medicine rotation. The emergency medicine rotation, however, is likely your best opportunity to learn procedural skills. Use this educational opportunity to your ad-vantage.
A final aspect of this core competency as defined by the ACGME in-cludes the ability “to work with health care professionals, including those from other disciplines, to provide patient-focused care.” This aspect of patient care is interwoven with professionalism and interpersonal and communication skills.
As defined by the ACGME, medical knowledge relates to the ability to demonstrate “an investigatory and analytic thinking approach to clinical situations, to know and apply the basic and clinically supportive sci-ences which are appropriate to their discipline.” The National Curriculum aimed to more clearly define these expectations as they relate to medical students. The competency of medical knowledge extends far beyond one’s fund of factual knowledge.
Students are expected to develop the skills necessary to evaluate an un-differentiated patient under a realm of chief complaints that include ab-dominal or pelvic pain, alteration or loss of consciousness, chest pain, gastrointestinal bleeding, headache, shock, shortness of breath, vaginal bleeding, eye pain or vision changes, overdose, weakness and dizziness, and traumatic complaints. Students are expected to develop a list of differential diagnoses, based on the patient’s presentation, which is prioritized not just by likelihood but by potential severity as it relates to morbidity and mortality.
In evaluating patients, a student should learn the indications, contrain-dications, and proper interpretations of the results of common diagnos-tic procedures and tests. Most importantly, students should cultivate an appreciation of pretest probabilities and risk. More important than any test result is the insight you need to develop throughout your career of when to trust, and when not to trust, that result.
Further adapting the definition of the medical knowledge core compe-tency for our specialty includes the immediate recall of selected information for the care of critical patients, an understanding of the use of medical resources for the immediate care of the patient, and the ability to apply this information to undifferentiated patient presentations. The traditional definitions used for competencies such as medical knowledge cross the boundaries of the other competencies. Medical knowledge in emergency medicine includes the acquisition of information from the patient (communication and interpersonal skills) and the application or delivery of the care (patient care).
Practice-Based Learning and Improvement
Practice-based learning and improvement is defined by the ACGME as “the ability to investigate and evaluate their patient care practices, ap-praise and assimilate scientific evidence, and improve patient care.” Practice-based learning can be learned through the systematically eval-uating patient care and population features; teaching other students and health care professionals; and applying knowledge gained from a systematic evaluation of the medical literature, including study design and statistical methodology.
Continuous Quality Improvement
As a student, you may not be aware of, or have access to, the continuous quality improvement (CQI) process that all hospital departments have in place. The CQI process is one venue in which patient care, department process issues, and other sensitive information are communicated in a legally protected environment. If there are any questions or concerns about the care a physician or resident has provided, it is openly discussed and the documentation is reviewed for standard of care, sys-tems issues, or documentation factors that may have contributed to an error or adverse outcome. Reviewed events are examined on several levels (systematic methodology) based on outcome, physician care, physician documentation, and resident supervision. The physicians involved are notified of the outcome and of suggestions for improvement. Opportunities to improve hospital and departmental practices are likewise identified and implemented.
Throughout medical school, students are exposed to journal club or a similar activity in which original research from the medical literature is critically appraised, often to answer a clinical question. Before gradua-tion, medical students should be introduced to the concept of reviewing the medical literature. This useful skill will be further reinforced during residency training. By understanding research methodology, you will be able to incorporate scientifically based principles into current practice, that is, evidence-based medicine.
Life-Long Self-Assessment and Continuous Osteopathic Learning Assessment
The Life-Long Self-Assessment (LLSA) and the Continuous Osteopathic Learning Assessment (COLA) are now being required for maintenance of emergency medicine board certification as a way to ensure that practic-ing emergency physicians keep current on recent literature. The annual LLSA and COLA examination covers articles or readings that have been chosen by a panel formed by the ABEM and the AOBEM, respectively.
The ACGME expects postgraduate trainees to use information technology to manage information, access online medical information, and be able to support self-directed learning. Many teaching institutions have software and other educational materials that may be used for your own or patient education. Online resources such as Up to Date or MD Consult and many others are available and can prove useful in bedside teaching and learning.
Teaching other health care professionals is an effective way to learn and represents an important contribution that you can make toward improv-ing patient care. This can be as simple as teaching nurses, technicians, or more junior students disease pathophysiology at the bedside or explaining the underlying rationale for your patient orders. More formal opportunities to teach may be available within your own institution. External formal courses to consider taking are advanced trauma life support, advanced cardiac life support, and pediatric advanced life support.
Practice-based learning and improvement is a career-long responsibility by which you remain current with all aspects of patient care. Practicing evidence-based medicine demonstrates your commitment to continual-ly providing the best care for your patients.
Consider a patient who requires a CT scan of the abdomen with oral and IV contrast. After the decision has been made to obtain this study, the patient needs to have a peripheral IV placed to administer IV contrast. What if this is difficult, and he or she requires multiple attempts? This takes time and nursing resources. The patient will often be required to have a basic metabolic profile performed to evaluate his or her renal function and of course drink oral contrast. Considering these steps, it may take 4 to 5 or more hours from the time that the study is ordered until the CT is officially interpreted by an attending radiologist. Adding to this time can be the unexpected emergencies and delays that can occur with transport, obtaining laboratory results, or other sick or injured patients requiring advanced imaging. Some hospital emergency departments may have access to only one CT scanner. Therefore, decisions will have to be made regarding resource utilization, allowing the more urgent patients to be imaged sooner than the less urgent patients.
As defined by the ACGME, systems-based practice is the “demonstrable awareness of and responsiveness to the larger content and system of health care and the ability to effectively call on system resources to provide care that is of optimal value.” It therefore extends beyond the individual pa-tient’s bedside to include an understanding of how your practice is affected by other practitioners, patients, and society at large, while considering the cost of health care and the allocation of health care resources. Understanding the “system” also involves learning how types of practices and health care delivery systems vary from one another, ways to advocate for patient care and assist patients in dealing with system complexities, and how to partner with healthcare managers and health care providers to assess, coordinate, and improve healthcare. Finally, com-petence with systems-based practice requires that you recognize how your actions and the system relate to each other.
A system is defined as interrelated components comprising a unified whole. Systems thinking is a technique for seeing and understanding interrelationships and the processes and barriers to change. The out-come desired for our medical practice—our unified mission—is to pro-vide high-quality patient care.
Access to routine health care is also a systems-based concern. It was estimated in 2004 that about 47 million Americans (16%) were without health insurance, a figure that continues to rise annually (Facts of Health Insurance Coverage, 2008). African Americans and Hispanics represent a disproportionate percentage of uninsured patients in this country. In addition, patients older than 65 and ethnic minorities use the emergency department for health care services at a rate much greater than that of the general population. Further, more than 19 million emergency de-partment visits annually are by patients without health insurance (Nawar, 2007). Lastly, approximately 20% of the uninsured population reports that their usual source of health care is the emergency department (Facts of Health Insurance Coverage, 2008).
In the 1990s as a way to promote a more efficient and cost-effective provision of health care, health maintenance organizations (HMOs) at-tempted to restrict the use of the emergency department for nonurgent patient complaints. At that time, various HMOs required a hospital emergency department to contact them to authorize reimbursement for the provision of emergency care. This resulted in significant consumer dissatisfaction. In recent years, the preauthorization requirements for patients requiring emergency medical services have been waived.
A systems-based approach to a patient’s health care may begin at home with the use of emergency medical services to transport a patient to a local emergency department. This extends through the clinical workup and management in the emergency department, possible hospitalization, follow-up care, and beyond. For many patient encounters, a decision has to be made regarding what, if any, diagnostic studies need to be performed. This appears to be a simple-enough task, but even this decision has ramifications. Does the test need to performed at 1:00 AM, or can the patient have the test performed the following morning or electively after discharge from the emergency department?
Some diagnostic imaging studies (MRI, certain ultrasounds, or vascular studies) require a technician to come to the hospital from home during off hours. Other tests may take hours to complete. Remember, an ultrasound of the abdomen or a CT scan of the brain costs money, and a patient or his or her insurance company is billed an extraordinary fee for these services. A hospital has to use laboratory technicians, phlebotomists, x-ray and CT technicians, trans-porters, nurses, and the like, all representing a cost to the overall health care system. In the larger picture, the overutilization or indiscriminate use of limited health care resources continues to drive up the cost of medical care. This is just one facet of what we as emergency physicians deal with when looking at the overall picture of a systems-based practice.
Some patients may require the assistance of a social worker or case manager. At some institutions, these resources are limited. This service is invaluable and may make the difference between a hospital admission or being able to safely discharge a patient home. Different system-related issues also arise for the patient that you plan to discharge home. At times, this may be because of the availability of follow-up health care, access to a specialist, ability to care for oneself, or the ability to pay for a new medication. Does the patient have access to follow-up heath care? Can the patient pay for his or her medication prescription? If the patient will be discharged before all test results are available (e.g., urine culture, formal radiograph interpretation), does your emergency department have a system in place to ensure that the final results or radiograph interpretation discrepancy will be reported to the patient in a timely fashion?
What if you were caring for a patient who could not recall important details of his or her past medical history? The retrieval of old medical records can be helpful for understanding pertinent aspects of the patient’s past medical history, medications, allergies, prior diagnostic test results, and the like. What mechanism is in place for the emergency physician or student to obtain this information? Some hospitals have an electronic medical record that makes all of this information easily available, whereas other hospitals may still rely on a paper system, which creates many difficulties when old records are urgently needed.
Although an electronic medical record or other computer-based information retrieval system can allow easy access to the medical record, prior test results, and more, it is a costly undertaking and requires a strong commitment from the hospital administration to provide the resources to develop the infrastructure. Not many years ago, to access old medical records in some institutions, a student or physician would have to go to the medical records department and read through a handwritten copy of the chart.
The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal statute enacted in 1986 and can be viewed as a nondiscriminatory statute. The basis for this legislation was to ensure that a patient presenting to an emergency department be provided with “an appropriate medical screening examination” to determine whether he or she is suffering from an “emergency medical condition” regardless of his or her ability to pay for medical care. The statute also governs a number of other issues that directly affect the practice of emergency medicine, including patient transfers and on-call physicians. Additional information on this topic can be found in Naradzay (2008).
Remember, systems-based practice involves CQI. This can be intradepartmental (morbidity and mortality conferences) or interdepartmental (hospitalwide peer review or performance improvement committees). Keep in mind that we are all part of one large system.
The ACGME defines professionalism as the following: “consistently demonstrate respect and compassion to others, manage conflict, and behave in a manner consistent with their values.” Professionalism should be viewed as an academic virtue, not just an expected set of behaviors. How-ever, professionalism is often less tangible and more difficult to evaluate than factual knowledge. Unprofessional behavior can run the gamut of behaviors, including substance abuse, lying, cheating, unexcused absences, or falsifying medical records. Unprofessional behavior in medical school is associated with future subsequent disciplinary action by a state medical board.
Professionalism involves the knowledge and ability to act in an ethical fashion, including the ability to be sensitive to patients regardless of cul-ture, age, or gender. Students exhibit professionalism through their motivation, integrity, honesty, and reliability. Furthermore, a student should interact appropriately with other members of the health care team and show respect for the people they encounter during shifts, including staff, peers, patients, and patients’ families.
Professionalism is also demonstrable in clinical management decisions, especially the ethical principles pertaining to the provision of withholding of clinical care, confidentiality of patient information, and informed consent. Regarding medical professionalism, students should be held to the same standards as physi-cians. They should demonstrate a responsiveness to the needs of patients and society that supersedes self-interest; be accountable to patients, society, and the profession; and demonstrate a commitment to excellence and ongoing professional development.
Typically, professionalism is observed in the clinical setting as well as the classroom. Adhering to an acceptable dress code and arriving on time for shifts are also within the realm of professionalism. These virtues are under constant observation by our colleagues, hospital administrators, staff, and of course patients and their families. Professional behavior is an expectation for all of us (students, residents, and attendings). As a medical student in the emergency department, your professionalism will be evaluated by your supervising resident or attending physician.
As you enter residency training, it is likely that your professional behavior and virtues will be evaluated on multiple levels. Within the ACGME toolbox of assessment methods, a “360-degree evaluation instrument” can be used to assess professional behaviors as well as other competencies; 360-degree evaluations consists of measurement tools that can be completed by peers, subordinates, patients, and their families [ACGME Outcomes Project and Accreditation Council for Graduate Medical Education American Board of Medical Specialties (ABMS), 2000].
Interpersonal and Communication Skills
The ACGME defines interpersonal and communication skills as “the ability to communicate with colleagues, staff, and family and to employ effective interpersonal skills that revolve around the care of a patient.” These skills go far beyond the ability to interview a patient and obtain an adequate history and are vital to the development of a competent, caring physician. Students must be able to demonstrate interpersonal and communication skills that result in effective information exchange and interaction with patients, families, and staff. This skill will become increasingly important when dealing with issues such as obtaining in-formed consent, delivering bad news, and resolving conflicts. The public has an expectation that a physician should be able to communicate in a caring and compassionate manner.
Interpersonal and communication skills encompass the effective establishment of a relationship with a patient and the ability to communicate with others on the health care team to deliver sound medical care. Students must also use effective listening skills and elicit and provide information using nonverbal, explanatory, questioning, and writing skills—each of which is crucial to your ability to work effectively with others as a member of the health care team. In addition, each of us needs to be aware of the image that we project and how we are perceived by others.
As emergency physicians, we pride ourselves on our interpersonal and communication skills. Every day we interact with patients and families in pain and stressful situations. We have to develop rapport with our patients when they are most vulnerable, and at times we have to deliver bad news. Our frequent interactions with primary care physicians, subspecialty consultants, and admission teams demand that we communicate effectively with our professional colleagues to provide high-quality medical care.
- Accreditation Council for Graduate Medical Education (ACGME). ACGME Program Requirements for Graduate Medical Education in Emergency Medicine. 2007. Available at: http://www.acgme.org/acWebsite/downloads/ RRC_progReq/110emergencymed07012007.pdf. Accessed March 10, 2008.
- This document outlines the program requirements for emergency medicine residency training.
- ACGME Outcomes Project and Accreditation Council for Graduate Medical Education American Board of Medical Specialties (ABMS). Toolbox of Assessment Methods. 2000. Available at: http://www.acgme.org/Outcome/ assess/Toolbox.pdf. Accessed March 10, 2008.
- This document includes descriptions of assessment methods.
- Naradzay JFX. COBRA laws and EMTALA. eMedicine; 2006. Available at: http://www.emedicine.com/emerg/topic737.htm. Accessed March 10, 2008.
- This article reviews the EMTALA statute.
- National Coalition on Health Care. Facts of Health Insurance Coverage. Washington, DC: National Coalition on Health Care. Available at: http://www.nchc.org/facts/coverage.shtml. Accessed March 11, 2008.
- This document provides fats on health insurance coverage.
- Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary. Adv Data Vital Health and Stat. 2007;386:1–32. Available at: http://www.cdc.gov/nchs/data/ad/ ad386.pdf. Accessed April 18, 2008.
- This article reviews nationally representative data on emergency department care in the United States. Data are from the 2005 National Hospital Ambulatory Medical Care Survey (NHAMCS).
- Stahmer SA, Ellison SR, Jubanyik KK, et al. Integrating the core competencies: proceeding from the 2005 Academic Assembly Consortium. Acad Emerg Med. 2007;14:80–94.
- This report provides a summary discussion of the status of integration of the core competencies into emergency medicine training programs in 2005.