How to Run an Emergency Medicine Residency Program

1
How to Run an Emergency Medicine Residency
Program
Jim Holliman, M.D., F.A.C.E.P. Professor of
Military and Emergency Medicine Uniformed
Services University Clinical Professor of
Emergency Medicine George Washington
University Bethesda, Maryland, U.S.A.
2
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

3
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 !

4
.
Essential Ingredients for a Successful E.M.
Residency Program

• 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

5
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.

6
.
Sample Text Lifted from the ACGME Web Site
Document Common Program Requirements (an 81
page document)
1. There must be a single program director with
authority and accountability for the operation of
the program. The sponsoring institutions GMEC
must approve a change in program director. After
approval, the program director must submit
this change 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 time adequate to maintain
continuity of leadership and program
stability. 3. Qualifications of the program
director must include a) requisite specialty
expertise and documented educational and
administrative experience acceptable to the
Review Committee b) current certification in the
specialty by the American Board of ________,
or specialty qualifications that are judged to be
acceptable by the Review Committee 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
environment conducive to educating the residents
in each of the ACGME competency areas.
The program director must a) oversee and ensure
the quality of didactic and clinical education in
all institutions that participate in the
program b) approve a local director at each
participating institution who is accountable for
resident education c) approve the selection of
program faculty as appropriate d) evaluate
program faculty and approve the continued
participation of program faculty based on
evaluation e) monitor resident supervision at
all participating institutions f) prepare and
submit all information required and requested by
the ACGME,
7
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.

8
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.

9
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, gt 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.

10
Facility Requirements for U.S. E.M. Residency
Programs

• Patient census gt 30,000 (total) per year.
• Pediatric census 15 or 4 months full time
  equivalent.
• Critically ill / injured patients at least 3
  of census or gt 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 lt 1 hour.
• Must have at least 5 hours per week didactic
  instruction by faculty.

11
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

12
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.

13
Requirements for Residents in U.S. E.M. Training
Programs

• May not work gt 12 hours continuously in E.D.
• May not have more than 60 hours per week total
  clinical time
• May not work gt 72 hours per week including
  on-call conferences
• Must have at least one day off in every 7 days
• Must be relieved of clinical duties sufficient to
  attend at least 70 of scheduled conferences
• gt 50 of rotations clinical time must be in
  E.D.
• Must keep a procedure logbook
• Must have followup information on admitted
  patients
• May not be supervised by resident physicians from
  specialties other than E.M. when in the E.D.

14
General Structure of U.S. E.M. Residency Programs
(cont.)

• gt 50 of time (gt 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

15
Non-E.D. E.M. Rotations Usually Included in E.M.
Residency Programs

• Toxicology
• Pre-hospital care
• Aeromedical care (flying usually optional for
  residents)
• Research
• 1 to 2 months of electives

16
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

17
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

18
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

19
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

20
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.

21
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

22
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)

23
Choices for E.M. Fellowship Training Programs
(following E.M. residency)

• Emergency Medical Services (Prehospital care) 1
  to 2 years
• Toxicology 2 years (separate subspecialty
  certification)
• Pediatric E.M. 2 years
• E.M. Research 1 to 2 years
• E.M. Administration 1 year
• E.M. Education 1 year
• Hyperbaric Medicine 1 year
• Sports Medicine 1 to 2 years
• Critical Care (Intensive Care) Medicine 1 to 2
  years
• Aeromedical Care 1 year
• International 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
24
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

25
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
26
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

27
The Six General Competencies the American Board
of Medical Specialties Has Tasked All Specialties
to Evaluate

• Patient care
• Medical knowledge
• Practice-based learning improvement
• Interpersonal communication skills
• Professionalism
• Systems-based practice

So the Evaluation(s) of residents and students
clinical performance should be linked to these 6
items
28
Example July Orientation for E.M. R1s 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.

29
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

30
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)
31
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

32
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

33
The American Board of E.M. (A.B.E.M.)
In-Training Exam

• Given once per year (February) to all E.M.
  residents at their residency site
• Similar in length and content to the A.B.E.M.
  certification exam
• Helps prepare residents for the certification
  exam
• 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

34
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).

35
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

36
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

37
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 training
• Locum tenens work

Program Directors should be able to prepare their
residents for any of these
38
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.