Emergency medicine in Australian medical student education

Clarabella Liew, Daryl Cheng & Jasmine Koh


Clarabella Liew
MBBS (Honours), Monash University
Intern, Singapore General Hospital

Daryl R Cheng
MBBS
Resident, Royal Children’s Hospital

Jasmine XW Koh
MBBS (Hons), Monash University
Emergency Registrar, Monash Health

Clarabella is an intern at the Singapore General Hospital with interests in critical care and public health. She also enjoys medical aid volunteering work and mentoring medical students.

Daryl is a resident at the Royal Children’s Hospital in Melbourne with a keen interest in paediatrics and medical student education. He also enjoys the diverse fields of global health, public health and emergency medicine.

Jasmine is a junior emergency registrar with Monash Health with special interests in paediatrics and infectious diseases. She hopes to do some volunteer work in developing countries in the future once she has gained enough experience and skills.


“The best way to predict the future is to invent it.” Alan Kay

Introduction

As the coalface of Australian healthcare, Emergency Medicine (EM) faces the growing healthcare challenges of the wider community. Today, these challenges form a unique ‘triple whammy’ – overseeing the implementation of the National Emergency Access Target (NEAT) or “4-hr rule”, in an effort to manage access block and emergency department overcrowding as a result of the increased care needs of an ageing population, whilst at the same time with limited resources attempting to maintain the quality of education and training of a burgeoning junior medical workforce. [1,2]

Amidst this conundrum, medical student EM education may sometimes be left in the shadows. [3,4] The unique arena of the emergency department with its volume, breadth and variety of undifferentiated patient cases not only provides countless learning opportunities for medical students but also allows them to contribute to healthcare teams in practical and meaningful ways. This ranges from assisting in initial assessments, to performing indicated procedures, to formulating discharges, and even research involvement. [5,6] All of which are useful and valuable skills favoured upon in a junior medical doctor and reduces the workload of the supervising team. [7-9] While some may argue that the general wards offer similar opportunities, the increasing attempts in improving efficiency and subspecialising medicine have led to the bulk of diagnostic and therapeutic interventions to be conducted in the emergency departments prior to acceptance by inpatient units. [4]

Students themselves find EM rotations extremely valuable, with many practical benefits for their future medical careers. [10] However, the already hectic and stressful EM work environment, coupled with enhanced time pressures from NEAT, increasing numbers of interns needing to complete an ED term, and the significant teaching and supervision requirements within EM departments may prove to be hurdles that limit the chances for medical students’ education. [11]

Thus, it may be prudent to re-examine this issue of our workforce challenges and to re-assess  medical student education.

  1. Could added investment in extension and evaluation of EM to medical students pique their interest in a future EM career?
  2. Would an increased focus on EM teaching better equip and innovate Australia’s future healthcare workforce?

Why is EM important in medical student education?

As a population-based specialty, EM education offers medical students a glimpse into the domain of public health. Patients present with illnesses and injuries that have high population prevalence, and presentations vary even across times of the day. Students are therefore exposed to a dynamic socioeconomic, cultural and demographic case mix. This serves to broaden not only the variety in conditions that students would see within an EM rotation, but also widens their perspectives on pertinent issues affecting different age groups in the Australian healthcare setting.

EM also provides an opportunity to learn about pre-hospital care, including co-ordinating ambulance and paramedic transfer services, retrieval, wilderness and disaster medicine.  Students encounter clinical scenarios they would not otherwise see such as occupational and environmental health, toxicology and trauma, and are also exposed to accident and injury surveillance, treatment and prevention.

EM has unique content areas that form the foundation of medical student training. In fact, EM exposure is seen as a form of clinical training assurance and a measured criterion for both students and junior doctors to be work-ready, and is considered essential and highly valuable as a core intern term in all states around Australia. [7]

With each undifferentiated presentation, students are encouraged to complete a focused history and examination, consider emergency interventions and prioritise differential diagnoses, rather than needing to pinpoint a correct diagnosis in a second. They then formulate streamlined investigation and management plans, and have opportunities to perform basic procedures which form part of the initial evaluation of many patients. Students can also receive positive feedback and critique from clinicians on their performance, and even observe and learn from their more senior colleagues in managing acutely ill patients. [4]

There are other unique benefits of students training in the ED environment. With the rollout of NEAT, clinicians may be increasingly pressured to make time-critical evaluations and decisions. Students would therefore not only be able to observe time and cost effective patient assessment strategies but also hone problem solving and task prioritisation skills. [12] The acute management of common ED presentations would be better appreciated as fewer patients stay in the ED for hours or days and are transferred to the wards within four hours. Furthermore, a minimum of 40% and up to 73.3% of patients within the ED are available for directed-learning purposed interaction with student doctors – a significantly higher percentage than inpatient wards. [4,13]

Many EDs now also contain short stay units (SSU) where patients requiring short admissions or periods of observation are managed. A multidisciplinary healthcare team is often involved in the care of these patients, and students are able to work with the team and are involved in allied health discussions and discharge planning meetings.

How can students learn more?

Access

Medical students are usually not rostered on overnight shifts due to a lack of senior medical staff and thus inadequate supervision. A 24-hour rostering of students may be one way to combat the need for more placement opportunities, provided it does not overload junior medical staff. Elective night shits have already been occurring though there is no current data evaluating medical students’ learning during those specific shifts. Nonetheless, there would be benefit in providing observational exposure to a different case-mix of patients, especially in resuscitation situations, where students can play a more hands-on role during night shifts.

E-learning

Simulation skills laboratories have been a proven tool in improving theoretical knowledge and procedural skills for medical students, especially in deteriorating patient or acute resuscitation scenarios. [14] These courses, along with other electronic resources can also be utilised for on or off-site learning. More traditional trauma training courses and more novel methods such as cadaver based simulation course for advanced emergency procedures have also proved useful in equipping medical students with basic and advanced procedural skills. [15]

Decision supports

Competency-based training including the use of logbooks and clinical pathways has been shown to improve quality of care in some areas of medicine. [16-18] Logbooks are currently used at various specialty training colleges including ACEM, and adoption for EM education can assist students to measure their abilities against a minimum standard. Medical diagnosis or treatment protocols or checklists can also guide students in developing a systematic approach to evaluating and treating various conditions.

How can students contribute more?

Previous research has shown the potential benefit that engaging medical students as paid assistants of the healthcare team can have on performance efficacy and workflow. Pilot projects have been tested in Germany and the USA. [8,9]

If introduced, a similar system within the EM departments where medical students assist in triaging patients, undertake basic procedures and complete preliminary paperwork alongside a nurse or rapid assessment clinician may expedite care and reduce waiting times for patients.  They could also aid in collating relevant medical information from GPs, specialists, residential care facilities and families. This would ease the paperwork burden for clinicians, improve efficacy of clinician-patient contact time and at the same time provide learning opportunities for students whilst collecting and synthesising information.

Medical students can also play an important role in academic aspects of EM. It is sometimes difficult for clinicians to allocate specific time for research whilst balancing patient care; thus students can assist in identification and recruitment of subjects, drafting of protocols and briefing of staff members on ongoing projects.

Where to from here?

The immediate challenges EM departments face should not deter EM clinicians’ involvement in training medical students for the future. [11] Rather, a collaborative effort with students to enhance EM learning will give future doctors a skillset applicable in any emergency scenario, regardless of specialty area.

As such, students’ feedback on EM rotations and learning techniques should be considered when planning EM curricula. Allocation of dedicated teaching time and educators along with adequate funding for implementation of various initiatives such as e-learning and simulation courses should also be made available for use.

Further research evaluating the current state of EM medical student education nationwide is crucial to identify key areas for improvement. Pilot projects testing novel ways such as those listed above to allow students to contribute to EM departments will also be beneficial to further evaluate innovative learning techniques.

Despite the added cost and effort required, EM training has proven invaluable for medical students and remains an essential part of their training. It is therefore highly recommended that EM continues to maintain a strong presence in medical students’ curriculum. [5]

Conflict of interest

None declared.

Acknowledgments

The authors would like to thank Dr Tony Kambourakis and Dr Simon Craig for their valuable assistance in guiding the development of this manuscript.

Correspondence

C Liew: cwlie2@student.monash.edu

References

[1] Braitberg G. Emergency department overcrowding: The solution to any problem is a matter of relativity. MJA. 2012;196(2):88-9.

[2] Chong A, Weiland TJ, Mackinlay C, Jelinek GA. The capacity of Australian ED to absorb the projected increase in intern numbers. Emerg Med Australas. 2010;22(2):100-7.

[3] Dowton SB, Stokes M, Rawstron EJ, Pogson PR, Brown MA. Postgraduate medical education: Rethinking and integrating a complex landscape.MJA. 2005;182(4);177-180.

[4] Celenza A. Evolution of emergency medicine teaching for medical students,Emerg Med Australas . 2006;18(3):219-220.

[5] Celenza A, Jelinek GA, Jacobs IG, Murray L, Graydon R, Kruk C. Implementation and evaluation of an undergraduate emergency medicine curriculum.  Emerg Med Australas. 2001;13:98–103.

[6] Aldeen AZ, Gisondi MA. Bedside teaching in the emergency department.Acad Emerg Med. 2006;13(8):860-6.

[7] (AMA). AMA. AMA Positional statement: Core terms in internship. 2007 [29 Feb 2012]; Available from: http://ama.com.au/node/2712.

[8] Schuld J, Justinger C, Kollmar O, Schilling MK, Richter S. Contribution of final-year medical students to operation room performance—economical and educational implications. Langenbeck Arch Surg. 2011;396(8):1239-44.

[9] Davis DJ, Moon M, Kennedy S, DelBasso S, Forman HP, Bokhari SA. Introducing medical students to radiology as paid emergency department triage assistants.JACR. 2011;8:710-5.

[10] Avegno JL, Murphy-Lavoie H, Lofaso D, Moreno-Walton L. Medical students’ perceptions of an emergency medicine clerkship: An analysis of self assessment surveys.IJEM. 2012;5(1):25. Epub [Epub ahead of print]

[11] Indraratna PL, Lucewicz A. Impact of the 4-hour emergency department target on medical student education.Emerg Med Australasia. 2011;23(6):784.

[12] Wald DA, Lin M, Manthey DE, Rogers RL, Zun LS, Christopher T. Emergency medicine in the medical school curriculum.Acad Emerg Med. 2010;17:S26-S30.

[13] Celenza A, Li J, Teng J. Medical student/student doctor access to patients in an emergency department.Emerg Med Australas. 2011;23(3):364-71.

[14] Langhan TS. Simulation training for emergency medicine residents: Time to move forward.CJEM. 2008;10:467-9.

[15] Tabas JA, Rosenson J, Price DD, Rohde D, Baird CH, Dhillon N. A comprehensive unembalmed cadaver based course in advanced emergency procedures for medical students.Acad Emerg Med. 2005;12:782-5.

[16] Taylor MD, Harrison G. Procedural skills quality assurance among Australasian College for Emergency Medicine fellows and trainees.Emerg Med Australas. 2006;18(3):268–275

[17] Nagler J, Harper MB, Bachur RG. An automated electronic case log: Using electronic information systems to assess training in emergency medicine.Acad Emerg Med . 2006;13:733-739.

[18] Chu T, Chang S, Hsieh B. The learning of 7th year medical students at internal medical – evaluation by logbooks. Ann Acad Med Singap. 2008;37:1002-7.