- Email: [email protected]
Academic emergency medicine: A national profile with and without emergency medicine residency programs
CONCEPTS academic emergency medicine; residency, emergency medicine
A c a d e m i c Emergency Medicine: A National Profile With and Without Emergency Medicine Residency Programs From the University of Colorado Health Sciences Center, Denver;* Case Western Reserve University, Cleveland, Ohioff
Steven M Chernow, MD*§ Charles L Emerman, MD~e Mark Langdorf, MD*§ Carl Schultz, MD*§
University of California, Irvine;t and Education Committee,
Study objective: Formal data are lacking regarding emergency departments in academic medical centers, particularly those without an emergency medicine residency program. The EducationCommittee of the Society for Academic EmergencyMedicine conducted a survey to define a national profile of academic emergencymedicine. Design: Prospectivesurvey with telephone follow-up.
Societyfor Academic Emergency
Academic medical centers.
Medicine, Lansing, Michigan.§
Setting:
Receivedfor publication
Participants: One hundred twenty-three academic medical centers as defined by the Association of American Medical Colleges.
October 29, 1991. Revision received March 9, 1992. Acceptedfor publication April 10, 1992. Presented at the Scientific Assembly of the American College of Emergency Physicians in San Francisco, September 1990.
Results: Results were obtained from 94 (78%)institutions: 27 (29%) had an emergencymedicine residency program and 67 (71%) had no emergency medicine residency program. Significant differences were found between those with and without emergency medicine residency programs regarding 24-hour attending coverage (96% versus 73%), mean weekly clinical faculty hours (26 versus 33), the number of emergency medicine board-certifiedfaculty, faculty recruitmentdifficulties (25% versus 75%); and the presence of a curriculum for housestaff (96% versus 38%). No significant differences were noted regarding the presence of a curriculum for medical students (78% versus 64%). Of the 67 institutions with no emergencymedicine residency programs, 42% were actively planning a program, and 42% would consider future development of a program. Conclusion: This article provides the first comprehensiveprofile of emergency medicine in the Association of American Medical Colleges academic medical centers. Programswith emergencymedicine residency programs provided more 24-hour attending coverage, had more emergency medicine board-certified faculty, and reported less difficulty recruiting additional faculty than institutions with no emergencymedicine residency program. Both need to expand their undergraduateeducational activities. Many institutions with no emergencymedicine residency program are attempting to develop emergencymedicine residency programs. [Chernow SM, Emerman CL, Langdorf M, Schultz C: Academic emergency medicine: A national profile with and without emergency medicine residencyprograms.Ann ErnergMeflAugust1992;21:947-951.]
AUGUST1992 21:8 ANNALS OF EMERGENCYMEDICINE
947/73
RESIDENCY PROGRAMS Chernow et al
INTRODUCTION
RESULTS
Emergency medicine is the newest of the medical specialties. Studies have attempted to clarify u n d e r g r a d u a t e emergency medical education in medical schools,i, 2 and the need for 24-hour attending coverage in emergency medicine residency programs.3, 4 Regulations regarding resident hours and attending coverage in emergency departments have recently been suggested. 5 Little formal information has been published regarding the clinical and academic environment of EDs in academic medical centers, particularly those with no emergency medicine residency program. We therefore surveyed all EDs, including those without a n emergency medicine residency, in academic medical centers as defined by the Association of American Medical Colleges. The purpose of the survey was to collect data on faculty, housestaff, and curriculums to provide a national profile of emergency medicine in the Association of American Medical Colleges academic medical centers and delineate differences between institutions with and without emergency medicine residency programs.
Of the 123 academic medical centers, 120 had EDs. Results were obtained from 94 of these institutions (78%), Of these, 27 (29%) h a d an emergency medicine residency program, and 67 (71%) had n o emergency medicine residency program. Fourteen (15%) were independent academic departments, and 64 were sections of other departments, including general surgery (41%) and internal medicine (38%). Attending clinical coverage is summarized (Figure 2). Twenty-four-hour ED attending coverage was provided in 26 (96%) of emergency medicine residency programs and in 49 (73%) Of the institutions with no emergency medicine residency p r o g r a m (X2 = 6.4, P = .01); 18% of institutions with no emergency medicine residency p r o g r a m provided 12 or fewer hours of ED attending coverage. The mean number of full-time faculty p e r 10,000 annual ED patient visits was 2.2 +_1.0 for emergency medicine residency programs and 1.76 + 1.2 for institutions with no emergency medicine residency program. The mean number of clinical hours p e r week for full-time faculty in institutions with emergency medicine residency programs was 26 + 4.3 hours compared with 33 + 9.2 hours for full-time faculty in institutions With no emergency medicine residency p r o g r a m (P = .0001). The mean number of clinical hours p e r week for full-time faculty in both types of institutions was 31 + 8.5. F o r t y - f o u r percent of the faculty in institutions with no emergency medicine residency programs and 62% of the faculty in emergency medicine residency programs published in the emergency medicine literature within the past five years. The percentage of faculty publishing correlated inversely with the required clinical hours (R = - 0 . 3 5 ; P < .002),
MATERIALS AND METHODS All 123 academic medical centers as defined by the Association of American Medical Colleges were surveyed between May 1989 and May 1990 (Figure ]).6 Telephone contact was made with each institution to obtain the name(s) of the ED director(s). A survey instrument was developed by the Education Committee of the Society of Academic Emergency Medicine. The survey was forwarded to the directors of the academic EDs. Telephone follow-up and repeat mailings were conducted for nonresponders. The survey requested information regarding the institution, faculty clinical coverage and publishing, b o a r d certification of faculty and directors, housestaff clinical hours and curriculum experience, u n d e r g r a d u a t e clinical rotations and curriculum, regular emergency medicine conferences, and future consideration regarding development of an emergency medicine residency program. Data were analyzed using the statistical analysis system. Values are expressed as proportions or as means _+s t a n d a r d deviation. Student's t-test was used to compare two means. Z2 analysis was performed to test the significance of differences in proportions. Figure 1. Association of American Medical Colleges criteria of American medical centers Must have a signed affiliation agreement with a college of medicine accredited bythe Liaison Committee on Medical Education Be a nonfederal member of the Association of American Medical College's Council of Teaching Hospitals Be under common ownership with a college of medicine, o r have most medical school department chairmen as the hospital chiefs of service, or have the chairman responsible for appointing the hospital chief of service Provide a short-stay, general hospital service
Figure 2. Hours of clinical attending coverage % of Programs
100~
~
2
4
hr
~
2
2
hr
75 16hr _<12hr
50i
25! II 0 No Emergency Medicine Residency Program* Emergency Medicine Residency Program "18%of institutionswithoutemergencymedicineresidency programshadunsupervisedhousestaffmorethan50%of thet~rne ~2 = 6,4
P = .01
74/948
ANNALS OF EMERGENCY MEDICINE
21:8
AUGUST1992
RESIDENCY PROGRAMS Chernow et al
The number of emergency medicine board-certified faculty per program is shown (Figure 3). Eighty percent of the faculty in emergency medicine residency programs were emergency medicine board-certified, and 50% of the faculty in institutions with no emergency medicine residency program were emergency medicine board-certified (P < .0001). Twenty percent of institutions with no emergency medicine residency program had no faculty who were board-certified in emergency medicine. Directors were emergency medicine boardcertified in 68% of institutions without emergency medicine residency programs. Additional faculty were needed in 66 (71%) of all programs. Seventy-nine percent of institutions with no emergency medicine residency program needed additional faculty, and 75% of these institutions reported difficulty in recruiting faculty; however, only 52% of institutions with an emergency medicine residency program reported the need for additional faculty, and only 25% of these reported difficulty in recruiting faculty. Reasons for recruitment difficulty included lack of available faculty (76%), salary (65%), unqualified faculty applicants (27%), and other factors (25%). Lack of available faculty (76%) and salary (65%) were the most commonly cited reasons. Clinical hours per week that housestaff provide coverage in the ED are summarized (Table). Surgical housestaff provided more clinical coverage than either internal medicine or emergency medicine housestaff; the mean numbers of clinical hours per week in the ED for surgical interns and junior and senior residents were 66.4, 74.2, and 85.3, respectively. A curriculum for housestaff was in place in 26 (96%) of emergency medicine residency programs and 24 (38%) of institutions with no emergency medicine residency program
(P< .00]). A medical student rotation was r e q u i r e d in 18% of all pro-
grams and offered in 93% of all programs. A curriculum for Figure 3. Number of emergency medicine board-certified faculty
2oPro=
~
WithoutEmergency Medicine ResidencyProgram With Emergency MedicineResidencyProgram
medical students was in place in 21 (78%) of emergency medicine residency programs and 42 (64%) of institutions without emergency medicine residency programs (P = NS). Emergency medicine faculty involvement in undergraduate education and curricula was rated from none to very active on a visual analog scale (Figure 4). Almost three quarters (72%) of all programs rated their faculty involvement in medical school undergraduate education and curriculum development as "less than moderate." Educational conferences included radiology (42%), mortality and morbidity (70%), core lectures (77%), and case conferences (81%). A laboratory, computer, and library were present in 59%, 87%, and 89%, respectively of all programs. Of the 67 institutions with no emergency medicine residency program, 28 (42%) were actively planning an emergency medicine residency, and an additional 28 (42%) would consider development in the future.
DISCUSSION This survey represents the first comprehensive profile of the EDs in academic medical centers as defined by the Association of American Medical Colleges. More than half of the medical students in the United States receive their emergency medicine training in these institutions. The information obtained illustrates that these academic medical centers are heterogeneous in many of their clinical and educational aspects. However, major differences were found between institutions with emergency medicine residency programs and those without emergency medicine residency programs. The data demonstrated that 24-hour attending coverage was much more prevalent in institutions with emergency medicine residency programs. Only one of the 27 emergency medicine residency programs did not provide 24-hour coverage, compared with 18 of the 67 institutions with no emergency medicine residency program. In 18% of the institutions with no emergency medicine residency program, unsupervised residents provided emergency care more than 50% of the day. This may lead to more mandated regulations and increased liability for those institutions.5 Because the Residency Review Committee for Emergency Medicine requires 24-hour attending Coverage, the one emergency medicine residency program that reported 16 hours of coverage was contacted by phone after the survey to clarify their response. The progra m stated that the Resident Review Table. Housestaff clinical hours per week in academic EDs
O
AUGUST1992
1
2
21:8
3
4 S No. of faculty
6-
7
ANNALS OF EMERGENCY MEDICINE
8
10+
Emergency medicine Internal medicine General surgery
Interns
Juniors
Seniors
No. Mean SD
No. Mean SD
No. Mean SD
20
49.1
9.2
24
47.9
7.8
26
44.0
62
51.9 12,9
44
49.3 12.4
32
47.5 15.2
51
66.4 21.2
25
74.2 23.7
9
85.3 15,8
8.7
949/75
RESIDENCY PROGRAMS C h e r n o w et al
Committee for Emergency Medicine had placed them on p r o bation for lack of 24-hour attending coverage. Subsequently, they changed their coverage to 24-hour coverage with double coverage for 17 of 24 hours. This example illustrates how the Resident Review Committee for Emergency Medicine establishes certain minimum guidelines of practice and education within the emergency medicine residency programs. Faculty in medical centers with an emergency medicine residency p r o g r a m were more likely to be board-certified in the specialty of emergency medicine. No faculty were b o a r d certified in emergency medicine in 20% of the institutions with no emergency medicine residency p r o g r a m , but all the emergency medicin e residency programs had three or more emergency medicine board-certified faculty. The n u m b e r o f mean clinical hours for faculty was higher in the institutions with no emergency medicine residency p r o g r a m compared with emergency medicine residency programs. One possible explanation for this is the additional teaching, administrative, and research responsibilities that a residency p r o g r a m requires. This survey confirms the manpower shortages of qualified academic emergency physicians. Seventy-one percent of all programs needed additional faculty. However, only 25% of emergency medicine residency programs r e p o r t e d difficulty recruiting faculty, compared with 75% of institutions with no emergency medicine residency program. P o s s i b l e reasons for the differences in recruiting ability might include increased job satisfaction, less clinical responsibilities, more teaching, administrative, and research opportunities, working with more boar&certified emergency medicine colleagues, and participating in the training of future emergency physicians. Regardless Of the exact reason, the data support that it was Figure 4, Faculty involvement in undergraduate education and curricula
60 ~ of Programs
I t
46%
40
30 ~-
2o! 14% 11% 10
10% 6%
None
76/950
Moderate Faculty Involvement
Very active
easier for emergency medicine residency programs to recruit faculty than institutions with no emergency medicine residency program. Housestaff clinical hours in the EDs demonstrated wide variations. All emergency medicine house officers provided less than 61 clinical hours p e r week of service as r e q u i r e d by the Resident Review Committee for Emergency Medicine. In Contrast, clinical hours of service by general surgery housestaff were consistently higher than either emergency medicine or internal medicine and would not be in compliance with recent suggested guidelines for EDs. 5 A formal curriculum for housestaff was available in 96% of emergency medicine residency programs, compared with 38% of institutions with no emergency medicine residency program. Such a curriculum would also be required by the Resident Review Committee for Emergency Medicine. A medical student 6urriculum was present in only 78% of emergency medicine residency programs and 64% of institutions with no emergency medicine residency program. Major improvements in educating undergraduates in emergency medicine are necessary in programs with and without emergency medicine residencies. The need for increased emergency medicine faculty involvement with u n d e r g r a d u a t e education is underscored by 72% of programs rating their participation as less than moderate. P r i o r surveys have emphasized the need for emergency medicine faculty to be active in u n d e r g r a d u a t e education.I, 2 Of interest, most EDs (87%) were equipped with a computer as well as a library. With p r o p e r software use, many programs could implement a computerized curriculum for their medical students. The need for quality emergency care and increased numbers of academic faculty may be improved with the development of more emergency medicine residency programs. Forty-two percent of the institutions with no emergency medicine residency p r o g r a m were actively planning such programs, and an additional 42% stated they would consider development in the future. With institutional and interdep a r t m e n t a l support, improved emergency medical services and education would be possible in these academic centers and the community at large. This study had some limitations. The target institutions were the Association of American Medical Colleges academic medical centers. This does not include all possible academic programs or all emergency medicine residency programs. No rigid definition for some of the terms on t h e survey were included, and there was no independent verification of the d a t a supplied by the medical centers that were surveyed. This allowed for some subjective interpretation by the programs for items such as what constitutes a curriculum. Finally, the survey was completed in May 1990, and data collected today might yield different results. Despite these limitations, this study provides an important documentation of the Association of American Medical Colleges academic medical centers and illustrates the heterogeneity of these institutions with r e g a r d to emergency medicine. It also illus-
ANNALS 0FEMER6ENCYMEDICINE 21:8 AUGUST1992
RESIDENCY PROGRAMS Chernow et al
trates the need to define carefully what is meant by such terms as a c a d e m i c e m e r g e n c y medicine and a c a d e m i c medical center. CONCLUSION
We surveyed the EDs in the 123 academic medical centers as defined by the Association of American Medical Colleges. Of the 120 institutions with EDs, 94 (78%) responded to the survey. Twenty-four-hour attending coverage and increased percentage of emergency medicine board-certified faculty were found in programs with an emergency medicine residency program. Many programs r e p o r t e d the need for additional faculty; however, programs without an emergency medicine residency p r o g r a m r e p o r t e d more recruitment difficulties. More involvement in emergency medicine undergraduate education is necessary from institutions with and without a residency program. Many institutions without an emergency medicine residency program are attempting to develop programs. F u t u r e surveys will assist in further defining the needs of our academic institutions with regard to emergency services.
REFERENCES 1. SandersAM, Criss E,Witzka D, et al: Survey of undergraduateemergency medical education in the United States. Ann Emerg Mad1986;15:19-23. 2. SandersAB, Criss E,Witzke D: Core content survey of undergraduateeducation in emergency medicine.Ann Emerg Mad 1986;15:27-32. 3. Henneman PL, HockbergerRS, Chiu C: Attending coverage in academic emergency medicine: A national survey. Ann Emerg Mad 1989;8:67-74. 4. KuhlmanTP, SchoonoverRW, HedgeRH, et al: Incidence of 24-hour faculty coverage in teaching EDs.J Emerg Med 1985;3:491-494. 5. Asch DA, Parker RM: The LibbyZion case: One step forward or two steps backward. N Engl J Mad 1988;318:771-775. 6. Academic Medical Center Hospitals. Washington, DC, Association of American Medical Colleges,May 24,1989.
Address for reprints: Steven M Chernow, MD, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Box B-215, Denver, Colorado 80262.
The authors appreciate and acknowledge the EmergencyMedicine Clinical Research Center at the University of Colorado Health Sciences Center for their support in statistical analysis. Special appreciation is extended to Priscilla LaCostefor her assistance in the preparation and transcription of the manuscript.
AUGUST1992
21:8 ANNALS OF EMERGENCY MEDICINE
951/77
A c a d e m i c Emergency Medicine: A National Profile With and Without Emergency Medicine Residency Programs From the University of Colorado Health Sciences Center, Denver;* Case Western Reserve University, Cleveland, Ohioff
Steven M Chernow, MD*§ Charles L Emerman, MD~e Mark Langdorf, MD*§ Carl Schultz, MD*§
University of California, Irvine;t and Education Committee,
Study objective: Formal data are lacking regarding emergency departments in academic medical centers, particularly those without an emergency medicine residency program. The EducationCommittee of the Society for Academic EmergencyMedicine conducted a survey to define a national profile of academic emergencymedicine. Design: Prospectivesurvey with telephone follow-up.
Societyfor Academic Emergency
Academic medical centers.
Medicine, Lansing, Michigan.§
Setting:
Receivedfor publication
Participants: One hundred twenty-three academic medical centers as defined by the Association of American Medical Colleges.
October 29, 1991. Revision received March 9, 1992. Acceptedfor publication April 10, 1992. Presented at the Scientific Assembly of the American College of Emergency Physicians in San Francisco, September 1990.
Results: Results were obtained from 94 (78%)institutions: 27 (29%) had an emergencymedicine residency program and 67 (71%) had no emergency medicine residency program. Significant differences were found between those with and without emergency medicine residency programs regarding 24-hour attending coverage (96% versus 73%), mean weekly clinical faculty hours (26 versus 33), the number of emergency medicine board-certifiedfaculty, faculty recruitmentdifficulties (25% versus 75%); and the presence of a curriculum for housestaff (96% versus 38%). No significant differences were noted regarding the presence of a curriculum for medical students (78% versus 64%). Of the 67 institutions with no emergencymedicine residency programs, 42% were actively planning a program, and 42% would consider future development of a program. Conclusion: This article provides the first comprehensiveprofile of emergency medicine in the Association of American Medical Colleges academic medical centers. Programswith emergencymedicine residency programs provided more 24-hour attending coverage, had more emergency medicine board-certified faculty, and reported less difficulty recruiting additional faculty than institutions with no emergencymedicine residency program. Both need to expand their undergraduateeducational activities. Many institutions with no emergencymedicine residency program are attempting to develop emergencymedicine residency programs. [Chernow SM, Emerman CL, Langdorf M, Schultz C: Academic emergency medicine: A national profile with and without emergency medicine residencyprograms.Ann ErnergMeflAugust1992;21:947-951.]
AUGUST1992 21:8 ANNALS OF EMERGENCYMEDICINE
947/73
RESIDENCY PROGRAMS Chernow et al
INTRODUCTION
RESULTS
Emergency medicine is the newest of the medical specialties. Studies have attempted to clarify u n d e r g r a d u a t e emergency medical education in medical schools,i, 2 and the need for 24-hour attending coverage in emergency medicine residency programs.3, 4 Regulations regarding resident hours and attending coverage in emergency departments have recently been suggested. 5 Little formal information has been published regarding the clinical and academic environment of EDs in academic medical centers, particularly those with no emergency medicine residency program. We therefore surveyed all EDs, including those without a n emergency medicine residency, in academic medical centers as defined by the Association of American Medical Colleges. The purpose of the survey was to collect data on faculty, housestaff, and curriculums to provide a national profile of emergency medicine in the Association of American Medical Colleges academic medical centers and delineate differences between institutions with and without emergency medicine residency programs.
Of the 123 academic medical centers, 120 had EDs. Results were obtained from 94 of these institutions (78%), Of these, 27 (29%) h a d an emergency medicine residency program, and 67 (71%) had n o emergency medicine residency program. Fourteen (15%) were independent academic departments, and 64 were sections of other departments, including general surgery (41%) and internal medicine (38%). Attending clinical coverage is summarized (Figure 2). Twenty-four-hour ED attending coverage was provided in 26 (96%) of emergency medicine residency programs and in 49 (73%) Of the institutions with no emergency medicine residency p r o g r a m (X2 = 6.4, P = .01); 18% of institutions with no emergency medicine residency p r o g r a m provided 12 or fewer hours of ED attending coverage. The mean number of full-time faculty p e r 10,000 annual ED patient visits was 2.2 +_1.0 for emergency medicine residency programs and 1.76 + 1.2 for institutions with no emergency medicine residency program. The mean number of clinical hours p e r week for full-time faculty in institutions with emergency medicine residency programs was 26 + 4.3 hours compared with 33 + 9.2 hours for full-time faculty in institutions With no emergency medicine residency p r o g r a m (P = .0001). The mean number of clinical hours p e r week for full-time faculty in both types of institutions was 31 + 8.5. F o r t y - f o u r percent of the faculty in institutions with no emergency medicine residency programs and 62% of the faculty in emergency medicine residency programs published in the emergency medicine literature within the past five years. The percentage of faculty publishing correlated inversely with the required clinical hours (R = - 0 . 3 5 ; P < .002),
MATERIALS AND METHODS All 123 academic medical centers as defined by the Association of American Medical Colleges were surveyed between May 1989 and May 1990 (Figure ]).6 Telephone contact was made with each institution to obtain the name(s) of the ED director(s). A survey instrument was developed by the Education Committee of the Society of Academic Emergency Medicine. The survey was forwarded to the directors of the academic EDs. Telephone follow-up and repeat mailings were conducted for nonresponders. The survey requested information regarding the institution, faculty clinical coverage and publishing, b o a r d certification of faculty and directors, housestaff clinical hours and curriculum experience, u n d e r g r a d u a t e clinical rotations and curriculum, regular emergency medicine conferences, and future consideration regarding development of an emergency medicine residency program. Data were analyzed using the statistical analysis system. Values are expressed as proportions or as means _+s t a n d a r d deviation. Student's t-test was used to compare two means. Z2 analysis was performed to test the significance of differences in proportions. Figure 1. Association of American Medical Colleges criteria of American medical centers Must have a signed affiliation agreement with a college of medicine accredited bythe Liaison Committee on Medical Education Be a nonfederal member of the Association of American Medical College's Council of Teaching Hospitals Be under common ownership with a college of medicine, o r have most medical school department chairmen as the hospital chiefs of service, or have the chairman responsible for appointing the hospital chief of service Provide a short-stay, general hospital service
Figure 2. Hours of clinical attending coverage % of Programs
100~
~
2
4
hr
~
2
2
hr
75 16hr _<12hr
50i
25! II 0 No Emergency Medicine Residency Program* Emergency Medicine Residency Program "18%of institutionswithoutemergencymedicineresidency programshadunsupervisedhousestaffmorethan50%of thet~rne ~2 = 6,4
P = .01
74/948
ANNALS OF EMERGENCY MEDICINE
21:8
AUGUST1992
RESIDENCY PROGRAMS Chernow et al
The number of emergency medicine board-certified faculty per program is shown (Figure 3). Eighty percent of the faculty in emergency medicine residency programs were emergency medicine board-certified, and 50% of the faculty in institutions with no emergency medicine residency program were emergency medicine board-certified (P < .0001). Twenty percent of institutions with no emergency medicine residency program had no faculty who were board-certified in emergency medicine. Directors were emergency medicine boardcertified in 68% of institutions without emergency medicine residency programs. Additional faculty were needed in 66 (71%) of all programs. Seventy-nine percent of institutions with no emergency medicine residency program needed additional faculty, and 75% of these institutions reported difficulty in recruiting faculty; however, only 52% of institutions with an emergency medicine residency program reported the need for additional faculty, and only 25% of these reported difficulty in recruiting faculty. Reasons for recruitment difficulty included lack of available faculty (76%), salary (65%), unqualified faculty applicants (27%), and other factors (25%). Lack of available faculty (76%) and salary (65%) were the most commonly cited reasons. Clinical hours per week that housestaff provide coverage in the ED are summarized (Table). Surgical housestaff provided more clinical coverage than either internal medicine or emergency medicine housestaff; the mean numbers of clinical hours per week in the ED for surgical interns and junior and senior residents were 66.4, 74.2, and 85.3, respectively. A curriculum for housestaff was in place in 26 (96%) of emergency medicine residency programs and 24 (38%) of institutions with no emergency medicine residency program
(P< .00]). A medical student rotation was r e q u i r e d in 18% of all pro-
grams and offered in 93% of all programs. A curriculum for Figure 3. Number of emergency medicine board-certified faculty
2oPro=
~
WithoutEmergency Medicine ResidencyProgram With Emergency MedicineResidencyProgram
medical students was in place in 21 (78%) of emergency medicine residency programs and 42 (64%) of institutions without emergency medicine residency programs (P = NS). Emergency medicine faculty involvement in undergraduate education and curricula was rated from none to very active on a visual analog scale (Figure 4). Almost three quarters (72%) of all programs rated their faculty involvement in medical school undergraduate education and curriculum development as "less than moderate." Educational conferences included radiology (42%), mortality and morbidity (70%), core lectures (77%), and case conferences (81%). A laboratory, computer, and library were present in 59%, 87%, and 89%, respectively of all programs. Of the 67 institutions with no emergency medicine residency program, 28 (42%) were actively planning an emergency medicine residency, and an additional 28 (42%) would consider development in the future.
DISCUSSION This survey represents the first comprehensive profile of the EDs in academic medical centers as defined by the Association of American Medical Colleges. More than half of the medical students in the United States receive their emergency medicine training in these institutions. The information obtained illustrates that these academic medical centers are heterogeneous in many of their clinical and educational aspects. However, major differences were found between institutions with emergency medicine residency programs and those without emergency medicine residency programs. The data demonstrated that 24-hour attending coverage was much more prevalent in institutions with emergency medicine residency programs. Only one of the 27 emergency medicine residency programs did not provide 24-hour coverage, compared with 18 of the 67 institutions with no emergency medicine residency program. In 18% of the institutions with no emergency medicine residency program, unsupervised residents provided emergency care more than 50% of the day. This may lead to more mandated regulations and increased liability for those institutions.5 Because the Residency Review Committee for Emergency Medicine requires 24-hour attending Coverage, the one emergency medicine residency program that reported 16 hours of coverage was contacted by phone after the survey to clarify their response. The progra m stated that the Resident Review Table. Housestaff clinical hours per week in academic EDs
O
AUGUST1992
1
2
21:8
3
4 S No. of faculty
6-
7
ANNALS OF EMERGENCY MEDICINE
8
10+
Emergency medicine Internal medicine General surgery
Interns
Juniors
Seniors
No. Mean SD
No. Mean SD
No. Mean SD
20
49.1
9.2
24
47.9
7.8
26
44.0
62
51.9 12,9
44
49.3 12.4
32
47.5 15.2
51
66.4 21.2
25
74.2 23.7
9
85.3 15,8
8.7
949/75
RESIDENCY PROGRAMS C h e r n o w et al
Committee for Emergency Medicine had placed them on p r o bation for lack of 24-hour attending coverage. Subsequently, they changed their coverage to 24-hour coverage with double coverage for 17 of 24 hours. This example illustrates how the Resident Review Committee for Emergency Medicine establishes certain minimum guidelines of practice and education within the emergency medicine residency programs. Faculty in medical centers with an emergency medicine residency p r o g r a m were more likely to be board-certified in the specialty of emergency medicine. No faculty were b o a r d certified in emergency medicine in 20% of the institutions with no emergency medicine residency p r o g r a m , but all the emergency medicin e residency programs had three or more emergency medicine board-certified faculty. The n u m b e r o f mean clinical hours for faculty was higher in the institutions with no emergency medicine residency p r o g r a m compared with emergency medicine residency programs. One possible explanation for this is the additional teaching, administrative, and research responsibilities that a residency p r o g r a m requires. This survey confirms the manpower shortages of qualified academic emergency physicians. Seventy-one percent of all programs needed additional faculty. However, only 25% of emergency medicine residency programs r e p o r t e d difficulty recruiting faculty, compared with 75% of institutions with no emergency medicine residency program. P o s s i b l e reasons for the differences in recruiting ability might include increased job satisfaction, less clinical responsibilities, more teaching, administrative, and research opportunities, working with more boar&certified emergency medicine colleagues, and participating in the training of future emergency physicians. Regardless Of the exact reason, the data support that it was Figure 4, Faculty involvement in undergraduate education and curricula
60 ~ of Programs
I t
46%
40
30 ~-
2o! 14% 11% 10
10% 6%
None
76/950
Moderate Faculty Involvement
Very active
easier for emergency medicine residency programs to recruit faculty than institutions with no emergency medicine residency program. Housestaff clinical hours in the EDs demonstrated wide variations. All emergency medicine house officers provided less than 61 clinical hours p e r week of service as r e q u i r e d by the Resident Review Committee for Emergency Medicine. In Contrast, clinical hours of service by general surgery housestaff were consistently higher than either emergency medicine or internal medicine and would not be in compliance with recent suggested guidelines for EDs. 5 A formal curriculum for housestaff was available in 96% of emergency medicine residency programs, compared with 38% of institutions with no emergency medicine residency program. Such a curriculum would also be required by the Resident Review Committee for Emergency Medicine. A medical student 6urriculum was present in only 78% of emergency medicine residency programs and 64% of institutions with no emergency medicine residency program. Major improvements in educating undergraduates in emergency medicine are necessary in programs with and without emergency medicine residencies. The need for increased emergency medicine faculty involvement with u n d e r g r a d u a t e education is underscored by 72% of programs rating their participation as less than moderate. P r i o r surveys have emphasized the need for emergency medicine faculty to be active in u n d e r g r a d u a t e education.I, 2 Of interest, most EDs (87%) were equipped with a computer as well as a library. With p r o p e r software use, many programs could implement a computerized curriculum for their medical students. The need for quality emergency care and increased numbers of academic faculty may be improved with the development of more emergency medicine residency programs. Forty-two percent of the institutions with no emergency medicine residency p r o g r a m were actively planning such programs, and an additional 42% stated they would consider development in the future. With institutional and interdep a r t m e n t a l support, improved emergency medical services and education would be possible in these academic centers and the community at large. This study had some limitations. The target institutions were the Association of American Medical Colleges academic medical centers. This does not include all possible academic programs or all emergency medicine residency programs. No rigid definition for some of the terms on t h e survey were included, and there was no independent verification of the d a t a supplied by the medical centers that were surveyed. This allowed for some subjective interpretation by the programs for items such as what constitutes a curriculum. Finally, the survey was completed in May 1990, and data collected today might yield different results. Despite these limitations, this study provides an important documentation of the Association of American Medical Colleges academic medical centers and illustrates the heterogeneity of these institutions with r e g a r d to emergency medicine. It also illus-
ANNALS 0FEMER6ENCYMEDICINE 21:8 AUGUST1992
RESIDENCY PROGRAMS Chernow et al
trates the need to define carefully what is meant by such terms as a c a d e m i c e m e r g e n c y medicine and a c a d e m i c medical center. CONCLUSION
We surveyed the EDs in the 123 academic medical centers as defined by the Association of American Medical Colleges. Of the 120 institutions with EDs, 94 (78%) responded to the survey. Twenty-four-hour attending coverage and increased percentage of emergency medicine board-certified faculty were found in programs with an emergency medicine residency program. Many programs r e p o r t e d the need for additional faculty; however, programs without an emergency medicine residency p r o g r a m r e p o r t e d more recruitment difficulties. More involvement in emergency medicine undergraduate education is necessary from institutions with and without a residency program. Many institutions without an emergency medicine residency program are attempting to develop programs. F u t u r e surveys will assist in further defining the needs of our academic institutions with regard to emergency services.
REFERENCES 1. SandersAM, Criss E,Witzka D, et al: Survey of undergraduateemergency medical education in the United States. Ann Emerg Mad1986;15:19-23. 2. SandersAB, Criss E,Witzke D: Core content survey of undergraduateeducation in emergency medicine.Ann Emerg Mad 1986;15:27-32. 3. Henneman PL, HockbergerRS, Chiu C: Attending coverage in academic emergency medicine: A national survey. Ann Emerg Mad 1989;8:67-74. 4. KuhlmanTP, SchoonoverRW, HedgeRH, et al: Incidence of 24-hour faculty coverage in teaching EDs.J Emerg Med 1985;3:491-494. 5. Asch DA, Parker RM: The LibbyZion case: One step forward or two steps backward. N Engl J Mad 1988;318:771-775. 6. Academic Medical Center Hospitals. Washington, DC, Association of American Medical Colleges,May 24,1989.
Address for reprints: Steven M Chernow, MD, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Box B-215, Denver, Colorado 80262.
The authors appreciate and acknowledge the EmergencyMedicine Clinical Research Center at the University of Colorado Health Sciences Center for their support in statistical analysis. Special appreciation is extended to Priscilla LaCostefor her assistance in the preparation and transcription of the manuscript.
AUGUST1992
21:8 ANNALS OF EMERGENCY MEDICINE
951/77