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Analyzing clinical case distributions to improve an emergency medicine clerkship
ORIGINAL CONTRIBUTION education, undergraduate, emergency medicine
Analyzing Clinical Case Distributions to Improve an Emergency Medicine Clerkship Recommendations for a core curriculum for undergraduate emergency medicine education have been published. It is expected that a combination of bedside teaching and didactic sessions will cover all aspects of the curriculum, but this has not been demonstrated. This study describes a method of using the distribution of clinical cases to shape the m i x of clinical and didactic learning in an emergency medicine clerkship. All senior students at the Albany Medical College participate in a four-week emergency medicine rotation. A brief log describing each clinical encounter is maintained by the students. Data from one year were sorted into 32 categories adapted from American College of Emergency Physicians guidelines and were tabulated. A criterion of 80% of students encountering at least one case in each category was chosen to ensure a reasonable level of exposure to a particular case or topic. One hundred twenty-three students were exposed to an average of 63.7 +_ 27.5 (SD) patients. Seven categories m e t the criterion, and the remaining 25 categories failed the criterion. Results indicate that exposure to certain categories of patients with appropriate monitoring can be reasonably ensured in our clinical setting. The didactic portion of the curriculum can be adjusted so that categories not meeting the clinical criterion will be emphasized, whereas those meeting the criterion will be de-emphasized. A method has been described that identifies gaps in the clinical exposure of students and permits appropriate identification of didactic sessions to create a clerkship more consistent with recommended guidelines. [De Lorenzo RA, Mayer D, Geehr EC: Analyzing clinical case distributions to improve an emergency medicine clerkship. Ann Emerg Med July 1990;19:746-751.]
INTRODUCTION
Robert A De Lorenzo Dan Mayer, MD Edward C Geehr, MD Albany, New York From the Department of Emergency Medicine, Albany Medical College, Albany, New York. Received for publication July 6, 1989. Revision received November 9, 1989. Accepted for publication February 15, 1990. Presented at the Society for Academic Emergency Medicine Annual Meeting in San Diego, May 1989, and at the Association of American Medical Colleges Annual Meeting in Washington, DC, October-November 1989. Supported in part by NIH Grant 5T35H L07506-09. Address for reprints: Dan Mayer, MD, Department of Emergency Medicine, A-139, Albany Medical College, Albany, New York 12208.
The American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) have recommended a core curriculum for undergraduate emergency medicine education. 1,z It is expected that a combination of bedside teaching and didactic sessions will cover all aspects of the curriculum. Previous surveys of undergraduate emergency medicine education indicate broad exposure to this subject in US medical colleges. The nature of the emergency medicine core curriculum in various programs has been described. 3-8 However, the effectiveness of clinical clerkships in exposing undergraduates to the core curriculum is unlrmown.4,9, lO This study describes a method of demonstrating the distribution of clinical cases through the use of a student case log to shape the mix of clinical and didactic learning in an emergency medicine clerkship. The clinical experience log has been used in family practice, psychiatry, physical medicine and rehabilitation, and allied health student clerkships to measure the distribution of cases seen by students. H-~7 These studies were used either to modify the students' case mix over their entire clinical experience or to describe the case mix in a given clerkship. This study demonstrates a method by which the data from student experience logs can be used to modify a clerkship in progress.
METHODS All senior medical students at Albany Medical College participate in a
19:7 July 1990
Annals of Emergency Medicine
746/45
CASE DISTRIBUTIONS De Lorenzo, Mayer & Geehr
FIGURE 1. Categories meeting crite-
rion.
14
F I G U R E 2. Categories not meeting
13 ----'~ 12 11 10
criterio]3. required four-week emergency medicine clerkship. Each student comp l e t e s 12 to 15 e i g h t - h o u r shifts for an average total of 105 hours in the clinical area. A p p r o x i m a t e l y four or five patients are seen per shift. Students w o r k directly w i t h the attending emergency physician and are expected to perform histories and physical examinations and present a d i f f e r e n t i a l d i a g n o s i s on c a s e s to w h i c h t h e y are assigned. The student t h e n f o l l o w s t h e p a t i e n t u n t i l discharge f r o m the e m e r g e n c y departm e n t or a d m i s s i o n to the hospital. A d d i t i o n a l i n s t r u c t i o n away from the bedside includes 13 hours of lectures, a s u t u r e laboratory, and a radiology c o n f e r e n c e . A d v a n c e d c a r d i a c life support i n s t r u c t i o n is offered by the d e p a r t m e n t b u t n o t a l w a y s concurrently w i t h the clerkship. During the study period, there were t h r e e sites at w h i c h s t u d e n t s saw patients - the A l b a n y Medical Center ED (a Level I t r a u m a center, w i t h 48,000 ED visits annually) and two local affiliated hospitals (Level II and III t r a u m a centers, each w i t h m o r e t h a n 30,000 v i s i t s annually). Except for severe trauma, each teaching s i t e r e c e i v e s an u n s e l e c t e d patient population. Approximately 80% of t h e s t u d e n t s s p e n d t w o weeks at the medical center and two w e e k s at an affiliated hospital; t h e r e m a i n i n g students spend the entire rotation at the medical center. P h y s i c i a n p r e c e p t o r s at the m e d i cal center are board certified or board eligible in e m e r g e n c y m e d i c i n e and hold academic appointments. Preceptors at t h e a f f i l i a t e d h o s p i t a l s are board c e r t i f i e d or b o a r d e l i g i b l e in emergency m e d i c i n e or in a primarycarc s p e c i a l t y and h o l d adjunct facu l t y positions. S t u d e n t s m a i n t a i n a brief log recording service date and age, presenting complaint, final diagnosis, and location of service of each patient encountered. Using the students' logged description, each case was sorted i n t o o n e of 32 c a t e g o r i e s a d a p t e d from the major headings detailed in ACEP a n d SAEM core c u r r i c u l u m (Table l). G a s e s s a t i s f y i n g t w o or more categories were placed into the 46/747
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one category judged to reflect the prim a r y clinical problem, whereas cases not satisfactorily fitting any category were p l a c e d i n t o t h e " o t h e r " category. P a t i e n t s p r e s e n t i n g for w o u n d checks or suture removal as well as A n n a l s of E m e r g e n c y
Medicine
illegible or i n c o m p l e t e e n t r i e s were categorized as " m i s c e l l a n e o u s . " Rand o m c h e c k s of s t u d e n t l o g s p e r formed by the clerkship coordinator as w e l l as t h e a t t e n d i n g p h y s i c i a n s h e l p e d e n s u r e s t u d e n t a c c u r a c y and 19:7 July 1990
TABLE 1. Clirlical category definitions
Heading
Cardiovascular
Trauma
Chest pain Cardiac arrest Hypertensive crisis Head Chest Abdominal Extremity
Gastrointestinal
Abdominal pain
Ophthalmological Pulmonary
Diarrhea Gastrointestinal bleed Trauma Red eye Dyspnea
Metabolic
Asthma Metabolic
Urogenital Toxicolog ic Pediatric Environmental ENT disease Nervous disease
Musculoskeletal
Diabetes Urinary tract infection ©bstetric/gynecologic Toxic Pediatric Environmental Ear, nose, throat Cerebrovascular Seizures Headache Musculoskeletal
Behavioral (gther
Psychiatric Upper respiratory infection Back pain Dermatologic ©ther Miscellaneous Modified from ACEP/SAEM guidelines.
diligence in c o m p l e t i n g the logs. D a t a from one year were tabulated and analyzed to d e t e r m i n e the distrib u t i o n of cases seen by each student and the class as a whole. A n IBM PC and s t a n d a r d s p r e a d s h e e t s o f t w a r e (Lotus 1-2-3} were used to c o m p l e t e the calculation. A criterion of 80% of students encountering at least one case in each c l i n i c a l category was c h o s e n to ensure a reasonable level of exposure to
19:7 July 1990
Definition
Category
Cardiac not otherwise specified Includes respiratory arrest All Including facial, cervical-spine; excluding burns, eye trauma Including rib fracture Including pelvic fracture Including soft-tissue injury, excluding musculoskeletal, burns Including nausea/vomiting; excluding obstetric/gynecologic Excluding pediatric All All All; excluding trauma Shortness of breath, cough, pneumonia, bronchitis All Acid/base, electrolyte, endocrine not otherwise specified All including hypoglycemia All; excluding obstetric/gynecologic All including pelvic inflammatory disease All including drug, alcohol, poison Child abuse, croup/epiglottitis, meningitis, seizures, diarrhea Burns, hyperthermia/hypothermia, insect bites All not otherwise specified Stroke, transient ischemic attack, syncope Excluding pediatric All Simple long-bone fracture, sprain, strain; excluding extremity trauma All Common cold, flu Chronic; excluding musculoskeletal All All not otherwise specified Wound checks, etc
a particular clinical category or teaching topic. Analysis of the distribution was made and categories m e e t i n g the criterion were identified and tested using a Z test comparison at a .05 confidence level.
RESULTS D u r i n g the academic year 1987-88, 123 of 124 s t u d e n t s c o m p l e t e d logs during their emergency medicine clerkship. The total n u m b e r of cases
Annals of Emergency Medicine
tabulated was 7,840 (average, 63.7 _+ 27.5 [SD] patients per student). The exposure level ranged from a l o w of 13 to a high of 152 patients per student, w i t h the vast m a j o r i t y encountering between 40 and 80 patients. Seven categories m e t the criterion of 80% of s t u d e n t s e n c o u n t e r i n g at least one patient during their clerkship. M u s c u l o s k e l e t a l injury was by far t h e c l i n i c a l category seen m o s t f r e q u e n t l y w i t h an average of eight
748/47
CASE DISTRIBUTIONS De Lorenzo, Mayer & Geehr
TABLE 2. Statistical data
Category
N
Mean
SD
% Students Encountering at Least One Patient
Musculoskeletal
991
8.0
5.0
98.5
Abdominal pain Head trauma
569 502
4.6 4.0
2.8 3.0
95.1 95.1
Extremity trauma Chest pain
548 401
4.8 3.2
4.0 2.5
93.5 91.0
Dyspnea
385
3.1
2.4
87.8
Ear, nose, and throat
384
3.1
2.4
87.8
Urinary tract infection Obstetric/gynecologic Back pain
325 311 320
2.6 2.5 2.6
2.0 1.9 2.1
86.9 86.1 82.1
Dermatologic
288
2.3
1.9
79.6
Upper respiratory infection Headache Other
297 204 201
2.4 1.7 1.6
2.1 1.5 1.5
79.6 74.8 74.8
Toxic Ophthalmologic trauma
190 170
1.5 1.4
1.5 1.3
70.7 69.1
Miscellaneous Pediatrics
227 206
1.8 1.7
2.1 2.2
69.1 58.5
Chest trauma Asthma Seizures Environmental Ce rebrovasc ular Psychiatric Gastrointestinal bleed Red eye Cardiac arrest Diarrhea Diabetes Metabolic Abdominal trauma Hypertensive crisis Not significant at P = .05
120 124 123 121 106 110 109 107 78 75 66 62 41 29
1.0 1.0 1.0 1.0 0.9 0.9 0.9 0.9 0.6 0.6 0.5 0.5 0.3 0.2
1.0 1.6 1.5 1.2 1.0 1.1 1.0 1.0 0.9 0.9 0.8 0.7 0.5 0.5
57.7 57.7 56.1 55.3 54.5 54.4 53.7 52.8 41.4 39.0 39.0 38.2 28.4 20.3
Significant at P ~< .05
encounters per student. The two next m o s t frequent categories were extremity trauma and abdominal pain with 4.8 and 4.6 encounters per student, r e s p e c t i v e l y . H e a d t r a u m a ; chest pain; ear, nose, and throat emergencies; and dyspnea were the other categories m e e t i n g the criterion. In addition, three other catego48/749
ties (urinary tract infections, back pain, and obstetric/gynecologic complaints) m e t the basic criterion but failed to satisfy the statistical significance requirements. The remaining 23 categories failed the criterion and ranged from a high of 2.3 p a t i e n t s per s t u d e n t (dermatologic) to a low of 0.2 for hyperAnnals of Emergency Medicine
tensive crisis. These results are summarized (Table 2), and the frequency of selected categories is depicted (Figures 1 and 2).
DISCUSSION Published guidelines on undergraduate emergency medicine form the foundation for teaching medical 19:7 July 1990
students.I, 2 Sanders et al a t t e m p t e d to broadly describe the core curricul u m ; h o w e v e r , to e n s u r e t h a t students receive appropriate exposure to the curriculum, a m e t h o d is needed to m o n i t o r s t u d e n t s ' e x p e r i e n c e at the bedside. 3-s O u r r e s u l t s i n d i c a t e that at our i n s t i t u t i o n seven important clinical categories are seen w i t h sufficient frequency as to reasonably ensure s t u d e n t exposure. Conversely, m a n y c l i n i c a l categories were seen less frequently and student exposure was n o t sufficient. In two categories ( h y p e r t e n s i v e e m e r g e n c i e s and abd o m i n a l trauma), exposure was rare, w i t h less t h a n 30% of the class seeing at least one case. The category m o s t frequently seen was m u s c u l o s k e l e t a l injuries. C o m b i n e d w i t h e x t r e m i t y t r a u m a , these t w o categories a c c o u n t e d for n e a r l y 20% of all cases seen. Thus, extremity and musculoskeletal injuries comprise a large proportion of the patient load seen in our clinical setting. O t h e r f o r m s of t r a u m a c o n t r i b u t e m u c h less to t h e o v e r a l l t o t a l , although head t r a u m a (which includes facial injuries) is statistically significant. General c o m p l a i n t s such as headache and chest, abdominal, and back p a i n w e r e e n c o u n t e r e d f a i r l y frequently. More specific complaints s u c h as d i a r r h e a a n d n e u r o l o g i c s y m p t o m s were seen less often. Specific derangements (urinary tract infections, t o x i c o l o g i c a l emergencies, and m e t a b o l i c d e r a n g e m e n t s ) w e r e variably seen. T h e s m a l l n u m b e r s of p e d i a t r i c and psychiatric patients seen by the students probably relate m o r e to the structure of the clerkship t h a n to the caseload seen by the participating EDs. M o s t p e d i a t r i c p a t i e n t s at t h e m e d i c a l center are seen by a s t u d e n t in a r e q u i r e d p e d i a t r i c clerkship. A separate psychiatric facility (with its o w n students) receives a p o r t i o n of the region's psychiatric emergencies. It is i n t e r e s t i n g to n o t e t h a t derm a t o l o g i c p r o b l e m s , w h i l e n o t specifically m e n t i o n e d in the core curriculum, comprise a n o t a b l e proportion of the patients seen by students. This situation, if duplicated at other i n s t i t u t i o n s , m a y n e e d t o b e addressed w h e n the core c u r r i c u l u m is revised. L i m i t a t i o n s of this study m a y restrict its usefulness in other settings and i n c l u d e a differing case m i x at 19:7 July 1990
other hospitals and a clerkship structure s u b s t a n t i a l l y different than that at A l b a n y Medical College. T h e basic m e t h o d of a n a l y z i n g a c l e r k s h i p ' s bedside exposure, however, is applicable to e m e r g e n c y m e d i c i n e clerkships at a n y location. Choosing a different c r i t e r i o n level w i l l o b v i o u s l y affect the n u m b e r of categories identified as satisfying the criterion. In a s i m i l a r f a s h i o n , m o d i f y i n g t h e 32 category definitions or changing the total n u m b e r of categories could alter the results. In addition, the student logs themselves m a y provide sources of error. W h i l e L i n k s et al s h o w e d s t u d e n t logs to be reasonably accurate w h e n c o m p a r e d w i t h f a c u l t y observation, l a x i t y or i n a c c u r a c y in c o m p l e t i n g the logs as well as having i n c o m p l e t e i n f o r m a t i o n available to the s t u d e n t (eg, final diagnoses) reduces the accuracy of the results. ~7 Examining t h e c o m p l e t e m e d i c a l record to validate the student's log entry m a y increase accuracy but could also have the undesirable side effect of distorting t h a t to w h i c h t h e s t u d e n t h a d a c t u a l l y been exposed. Using the information obtained from the case logs, several modificat i o n s h a v e b e e n p l a n n e d for t h e clerkship. Students w i l l be encouraged to see a m i n i m u m of one each of c e r t a i n p a t i e n t s . T h e y w i l l b e given a sheet listing the seven clinical categories (Figure 1). W h e n e v e r a p a t i e n t w i t h one of the problems on the list is seen, the student will n o t e it and t h e n discuss the patient at t h e bedside w i t h the attending physician. A guide listing the differential diagnoses and i m p o r t a n t p o i n t s is provided to the s t u d e n t and f a c u l t y to facilitate discussion. As a r e s u l t of a n a l y z i n g the students' case distribution, a decrease in lecture and conference t i m e spent on selected categories has been achieved for those clinical areas where bedside teaching is predictable. This has allowed an increase in the n u m b e r of t o p i c s c o v e r e d in d i d a c t i c s e s s i o n s w i t h o u t increasing the t i m e assigned t h e s e sessions. Thus, t h e c o n t e n t , n o t j u s t the format, of t h e d i d a c t i c sessions has been adjusted to reflect a c o n s i s t e n t level of bedside teaching. Total clinical hours and reading assignments from standard t e x t b o o k s r e m a i n unchanged. However, a n e w c a s e - o r i e n t e d t e x t for m e d i c a l stud e n t s is c u r r e n t l y u n d e r d e v e l o p Annals of Emergency Medicine
ment. This text, modified after t h a t b y Platt, 18 w i l l c o n t a i n all the elem e n t s in the ACEP/SAEM guidelines for u n d e r g r a d u a t e e m e r g e n c y m e d i cine education. The approximately 20% of s t u d e n t s w h o do n o t see a p a r t i c u l a r c l i n i c a l c a t e g o r y at t h e bedside can be directed to read a n d discuss the a p p r o p r i a t e case in t h e textbook. CONCLUSION The study of cases seen by all sen i o r m e d i c a l s t u d e n t s in a r e q u i r e d f o u r - w e e k c l e r k s h i p in e m e r g e n c y m e d i c i n e has allowed us to identify clinical case categories seen at a fieq u e n c y that m e e t s a p r e d e t e r m i n e d c r i t e r i o n . T h i s i n f o r m a t i o n has allowed us to p l a n modifications in t h e d i d a c t i c p o r t i o n of the c l e r k s h i p to better c o m p l e m e n t the learning t h a t occurs at the bedside. The authors thank Barbara Norton for her assistance in administrating the study and Rosemarie Lupoli for typing the manuscript.
REFERENCES
1. Society of Teachers of Emergency Medicine: Core content for undergraduate education in emergency medicine. Ann Emerg Med 1985;14: 474-476. 2. American College of Emergency Physicians: Guidelines for undergraduate education in emergency medicine. Ann Emerg Med 1987;16: 117-119. 3. Sanders AB, Criss E, Witzke D: Core content survey of undergraduate education in emergency medicine. Ann Emerg Med 1986;15:6-11. 4. Sanders AB, Criss E, Witzke D: Survey of undergraduate emergency medical education in the United States. Ann Emerg Med t986;15:1-5. 5. Sanders AB, Criss E, Witzke DB: Emergency medicine skills and topics in undergraduate education. Proc Annu Conf Res Med Educ 1985: 83-87. 6. Lunenfeld E, Levin M, Lazin R: Emergency core curriculum of the Beer Shiva medical school. Isr J Med Sci 1987;23:1038-1040. 7. Shesser R, Smith M, Kline P, et al: A cost effective emergency medicine clerkship. J Med Educ 1985;60:288-292. 8. Klausner JM, Rozin RR: Undergraduate eduk cation in emergency medicine and initial man agement of trauma casualties in Israel. Milit Med 1987;152:458-461. 9. Browns CG, Sanders AB, Gurley HT, et al: Curriculum for undergraduate education in emergency medicine. J Med Educ 1984;59: 427-429. I0. Kline P, Shesser R, Smith M, et al: Comparison of videotape instructional program with a traditional lecture series for medical student emergency medicine teaching. Ann Emerg Med 1986;15:16q8. 750/49
CASE DISTRIBUTIONS De Lorenzo, Mayer & Geehr
11. Munro JGC: Computer analysis of the student log diary: An aid in teaching of general practice and family medicine. Med Educ 1984; 18:75-79. 12. Hobbs J, Mongan P, Miller MD: A system for assessing clerkship experience using a logbook and microcomputers. Faro Med 1987;19: 133-136. 13. Shesser R, Smith M, Kline P, et al: A stu-
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dent emergency medicine clerkship that uses new infornration technologies. J Emerg Med I985;2:455-461. 14. Jones ME, Sinaki M, McPhee MC: Medical Students: Learning experience in physical medicine and rehabilitation. Arch Phys Med Rehabil 1984;65:40t-403. 15. Wells PA, Lessard E: Survey of student clinical practice. Phys Ther Apt 1986;66:551-554.
Annals of Emergency Medicine
16. Niland-Weiss J, Duda M, Dreskin M, et al: Computerized evaluation of clinical experience in the training of health professionals. I Allied Health 1985;14:255-266. 17. Links P8, Foley F, Feltham R: The educational value of student encounter logs in a psychiatry clerkship. Med Teach 1988;10:33-40. 18. Platt FW: Case studies in Emergency Medicine. Boston, Little, Brown and Co, 1974.
19:7 July 1990
Analyzing Clinical Case Distributions to Improve an Emergency Medicine Clerkship Recommendations for a core curriculum for undergraduate emergency medicine education have been published. It is expected that a combination of bedside teaching and didactic sessions will cover all aspects of the curriculum, but this has not been demonstrated. This study describes a method of using the distribution of clinical cases to shape the m i x of clinical and didactic learning in an emergency medicine clerkship. All senior students at the Albany Medical College participate in a four-week emergency medicine rotation. A brief log describing each clinical encounter is maintained by the students. Data from one year were sorted into 32 categories adapted from American College of Emergency Physicians guidelines and were tabulated. A criterion of 80% of students encountering at least one case in each category was chosen to ensure a reasonable level of exposure to a particular case or topic. One hundred twenty-three students were exposed to an average of 63.7 +_ 27.5 (SD) patients. Seven categories m e t the criterion, and the remaining 25 categories failed the criterion. Results indicate that exposure to certain categories of patients with appropriate monitoring can be reasonably ensured in our clinical setting. The didactic portion of the curriculum can be adjusted so that categories not meeting the clinical criterion will be emphasized, whereas those meeting the criterion will be de-emphasized. A method has been described that identifies gaps in the clinical exposure of students and permits appropriate identification of didactic sessions to create a clerkship more consistent with recommended guidelines. [De Lorenzo RA, Mayer D, Geehr EC: Analyzing clinical case distributions to improve an emergency medicine clerkship. Ann Emerg Med July 1990;19:746-751.]
INTRODUCTION
Robert A De Lorenzo Dan Mayer, MD Edward C Geehr, MD Albany, New York From the Department of Emergency Medicine, Albany Medical College, Albany, New York. Received for publication July 6, 1989. Revision received November 9, 1989. Accepted for publication February 15, 1990. Presented at the Society for Academic Emergency Medicine Annual Meeting in San Diego, May 1989, and at the Association of American Medical Colleges Annual Meeting in Washington, DC, October-November 1989. Supported in part by NIH Grant 5T35H L07506-09. Address for reprints: Dan Mayer, MD, Department of Emergency Medicine, A-139, Albany Medical College, Albany, New York 12208.
The American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) have recommended a core curriculum for undergraduate emergency medicine education. 1,z It is expected that a combination of bedside teaching and didactic sessions will cover all aspects of the curriculum. Previous surveys of undergraduate emergency medicine education indicate broad exposure to this subject in US medical colleges. The nature of the emergency medicine core curriculum in various programs has been described. 3-8 However, the effectiveness of clinical clerkships in exposing undergraduates to the core curriculum is unlrmown.4,9, lO This study describes a method of demonstrating the distribution of clinical cases through the use of a student case log to shape the mix of clinical and didactic learning in an emergency medicine clerkship. The clinical experience log has been used in family practice, psychiatry, physical medicine and rehabilitation, and allied health student clerkships to measure the distribution of cases seen by students. H-~7 These studies were used either to modify the students' case mix over their entire clinical experience or to describe the case mix in a given clerkship. This study demonstrates a method by which the data from student experience logs can be used to modify a clerkship in progress.
METHODS All senior medical students at Albany Medical College participate in a
19:7 July 1990
Annals of Emergency Medicine
746/45
CASE DISTRIBUTIONS De Lorenzo, Mayer & Geehr
FIGURE 1. Categories meeting crite-
rion.
14
F I G U R E 2. Categories not meeting
13 ----'~ 12 11 10
criterio]3. required four-week emergency medicine clerkship. Each student comp l e t e s 12 to 15 e i g h t - h o u r shifts for an average total of 105 hours in the clinical area. A p p r o x i m a t e l y four or five patients are seen per shift. Students w o r k directly w i t h the attending emergency physician and are expected to perform histories and physical examinations and present a d i f f e r e n t i a l d i a g n o s i s on c a s e s to w h i c h t h e y are assigned. The student t h e n f o l l o w s t h e p a t i e n t u n t i l discharge f r o m the e m e r g e n c y departm e n t or a d m i s s i o n to the hospital. A d d i t i o n a l i n s t r u c t i o n away from the bedside includes 13 hours of lectures, a s u t u r e laboratory, and a radiology c o n f e r e n c e . A d v a n c e d c a r d i a c life support i n s t r u c t i o n is offered by the d e p a r t m e n t b u t n o t a l w a y s concurrently w i t h the clerkship. During the study period, there were t h r e e sites at w h i c h s t u d e n t s saw patients - the A l b a n y Medical Center ED (a Level I t r a u m a center, w i t h 48,000 ED visits annually) and two local affiliated hospitals (Level II and III t r a u m a centers, each w i t h m o r e t h a n 30,000 v i s i t s annually). Except for severe trauma, each teaching s i t e r e c e i v e s an u n s e l e c t e d patient population. Approximately 80% of t h e s t u d e n t s s p e n d t w o weeks at the medical center and two w e e k s at an affiliated hospital; t h e r e m a i n i n g students spend the entire rotation at the medical center. P h y s i c i a n p r e c e p t o r s at the m e d i cal center are board certified or board eligible in e m e r g e n c y m e d i c i n e and hold academic appointments. Preceptors at t h e a f f i l i a t e d h o s p i t a l s are board c e r t i f i e d or b o a r d e l i g i b l e in emergency m e d i c i n e or in a primarycarc s p e c i a l t y and h o l d adjunct facu l t y positions. S t u d e n t s m a i n t a i n a brief log recording service date and age, presenting complaint, final diagnosis, and location of service of each patient encountered. Using the students' logged description, each case was sorted i n t o o n e of 32 c a t e g o r i e s a d a p t e d from the major headings detailed in ACEP a n d SAEM core c u r r i c u l u m (Table l). G a s e s s a t i s f y i n g t w o or more categories were placed into the 46/747
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one category judged to reflect the prim a r y clinical problem, whereas cases not satisfactorily fitting any category were p l a c e d i n t o t h e " o t h e r " category. P a t i e n t s p r e s e n t i n g for w o u n d checks or suture removal as well as A n n a l s of E m e r g e n c y
Medicine
illegible or i n c o m p l e t e e n t r i e s were categorized as " m i s c e l l a n e o u s . " Rand o m c h e c k s of s t u d e n t l o g s p e r formed by the clerkship coordinator as w e l l as t h e a t t e n d i n g p h y s i c i a n s h e l p e d e n s u r e s t u d e n t a c c u r a c y and 19:7 July 1990
TABLE 1. Clirlical category definitions
Heading
Cardiovascular
Trauma
Chest pain Cardiac arrest Hypertensive crisis Head Chest Abdominal Extremity
Gastrointestinal
Abdominal pain
Ophthalmological Pulmonary
Diarrhea Gastrointestinal bleed Trauma Red eye Dyspnea
Metabolic
Asthma Metabolic
Urogenital Toxicolog ic Pediatric Environmental ENT disease Nervous disease
Musculoskeletal
Diabetes Urinary tract infection ©bstetric/gynecologic Toxic Pediatric Environmental Ear, nose, throat Cerebrovascular Seizures Headache Musculoskeletal
Behavioral (gther
Psychiatric Upper respiratory infection Back pain Dermatologic ©ther Miscellaneous Modified from ACEP/SAEM guidelines.
diligence in c o m p l e t i n g the logs. D a t a from one year were tabulated and analyzed to d e t e r m i n e the distrib u t i o n of cases seen by each student and the class as a whole. A n IBM PC and s t a n d a r d s p r e a d s h e e t s o f t w a r e (Lotus 1-2-3} were used to c o m p l e t e the calculation. A criterion of 80% of students encountering at least one case in each c l i n i c a l category was c h o s e n to ensure a reasonable level of exposure to
19:7 July 1990
Definition
Category
Cardiac not otherwise specified Includes respiratory arrest All Including facial, cervical-spine; excluding burns, eye trauma Including rib fracture Including pelvic fracture Including soft-tissue injury, excluding musculoskeletal, burns Including nausea/vomiting; excluding obstetric/gynecologic Excluding pediatric All All All; excluding trauma Shortness of breath, cough, pneumonia, bronchitis All Acid/base, electrolyte, endocrine not otherwise specified All including hypoglycemia All; excluding obstetric/gynecologic All including pelvic inflammatory disease All including drug, alcohol, poison Child abuse, croup/epiglottitis, meningitis, seizures, diarrhea Burns, hyperthermia/hypothermia, insect bites All not otherwise specified Stroke, transient ischemic attack, syncope Excluding pediatric All Simple long-bone fracture, sprain, strain; excluding extremity trauma All Common cold, flu Chronic; excluding musculoskeletal All All not otherwise specified Wound checks, etc
a particular clinical category or teaching topic. Analysis of the distribution was made and categories m e e t i n g the criterion were identified and tested using a Z test comparison at a .05 confidence level.
RESULTS D u r i n g the academic year 1987-88, 123 of 124 s t u d e n t s c o m p l e t e d logs during their emergency medicine clerkship. The total n u m b e r of cases
Annals of Emergency Medicine
tabulated was 7,840 (average, 63.7 _+ 27.5 [SD] patients per student). The exposure level ranged from a l o w of 13 to a high of 152 patients per student, w i t h the vast m a j o r i t y encountering between 40 and 80 patients. Seven categories m e t the criterion of 80% of s t u d e n t s e n c o u n t e r i n g at least one patient during their clerkship. M u s c u l o s k e l e t a l injury was by far t h e c l i n i c a l category seen m o s t f r e q u e n t l y w i t h an average of eight
748/47
CASE DISTRIBUTIONS De Lorenzo, Mayer & Geehr
TABLE 2. Statistical data
Category
N
Mean
SD
% Students Encountering at Least One Patient
Musculoskeletal
991
8.0
5.0
98.5
Abdominal pain Head trauma
569 502
4.6 4.0
2.8 3.0
95.1 95.1
Extremity trauma Chest pain
548 401
4.8 3.2
4.0 2.5
93.5 91.0
Dyspnea
385
3.1
2.4
87.8
Ear, nose, and throat
384
3.1
2.4
87.8
Urinary tract infection Obstetric/gynecologic Back pain
325 311 320
2.6 2.5 2.6
2.0 1.9 2.1
86.9 86.1 82.1
Dermatologic
288
2.3
1.9
79.6
Upper respiratory infection Headache Other
297 204 201
2.4 1.7 1.6
2.1 1.5 1.5
79.6 74.8 74.8
Toxic Ophthalmologic trauma
190 170
1.5 1.4
1.5 1.3
70.7 69.1
Miscellaneous Pediatrics
227 206
1.8 1.7
2.1 2.2
69.1 58.5
Chest trauma Asthma Seizures Environmental Ce rebrovasc ular Psychiatric Gastrointestinal bleed Red eye Cardiac arrest Diarrhea Diabetes Metabolic Abdominal trauma Hypertensive crisis Not significant at P = .05
120 124 123 121 106 110 109 107 78 75 66 62 41 29
1.0 1.0 1.0 1.0 0.9 0.9 0.9 0.9 0.6 0.6 0.5 0.5 0.3 0.2
1.0 1.6 1.5 1.2 1.0 1.1 1.0 1.0 0.9 0.9 0.8 0.7 0.5 0.5
57.7 57.7 56.1 55.3 54.5 54.4 53.7 52.8 41.4 39.0 39.0 38.2 28.4 20.3
Significant at P ~< .05
encounters per student. The two next m o s t frequent categories were extremity trauma and abdominal pain with 4.8 and 4.6 encounters per student, r e s p e c t i v e l y . H e a d t r a u m a ; chest pain; ear, nose, and throat emergencies; and dyspnea were the other categories m e e t i n g the criterion. In addition, three other catego48/749
ties (urinary tract infections, back pain, and obstetric/gynecologic complaints) m e t the basic criterion but failed to satisfy the statistical significance requirements. The remaining 23 categories failed the criterion and ranged from a high of 2.3 p a t i e n t s per s t u d e n t (dermatologic) to a low of 0.2 for hyperAnnals of Emergency Medicine
tensive crisis. These results are summarized (Table 2), and the frequency of selected categories is depicted (Figures 1 and 2).
DISCUSSION Published guidelines on undergraduate emergency medicine form the foundation for teaching medical 19:7 July 1990
students.I, 2 Sanders et al a t t e m p t e d to broadly describe the core curricul u m ; h o w e v e r , to e n s u r e t h a t students receive appropriate exposure to the curriculum, a m e t h o d is needed to m o n i t o r s t u d e n t s ' e x p e r i e n c e at the bedside. 3-s O u r r e s u l t s i n d i c a t e that at our i n s t i t u t i o n seven important clinical categories are seen w i t h sufficient frequency as to reasonably ensure s t u d e n t exposure. Conversely, m a n y c l i n i c a l categories were seen less frequently and student exposure was n o t sufficient. In two categories ( h y p e r t e n s i v e e m e r g e n c i e s and abd o m i n a l trauma), exposure was rare, w i t h less t h a n 30% of the class seeing at least one case. The category m o s t frequently seen was m u s c u l o s k e l e t a l injuries. C o m b i n e d w i t h e x t r e m i t y t r a u m a , these t w o categories a c c o u n t e d for n e a r l y 20% of all cases seen. Thus, extremity and musculoskeletal injuries comprise a large proportion of the patient load seen in our clinical setting. O t h e r f o r m s of t r a u m a c o n t r i b u t e m u c h less to t h e o v e r a l l t o t a l , although head t r a u m a (which includes facial injuries) is statistically significant. General c o m p l a i n t s such as headache and chest, abdominal, and back p a i n w e r e e n c o u n t e r e d f a i r l y frequently. More specific complaints s u c h as d i a r r h e a a n d n e u r o l o g i c s y m p t o m s were seen less often. Specific derangements (urinary tract infections, t o x i c o l o g i c a l emergencies, and m e t a b o l i c d e r a n g e m e n t s ) w e r e variably seen. T h e s m a l l n u m b e r s of p e d i a t r i c and psychiatric patients seen by the students probably relate m o r e to the structure of the clerkship t h a n to the caseload seen by the participating EDs. M o s t p e d i a t r i c p a t i e n t s at t h e m e d i c a l center are seen by a s t u d e n t in a r e q u i r e d p e d i a t r i c clerkship. A separate psychiatric facility (with its o w n students) receives a p o r t i o n of the region's psychiatric emergencies. It is i n t e r e s t i n g to n o t e t h a t derm a t o l o g i c p r o b l e m s , w h i l e n o t specifically m e n t i o n e d in the core curriculum, comprise a n o t a b l e proportion of the patients seen by students. This situation, if duplicated at other i n s t i t u t i o n s , m a y n e e d t o b e addressed w h e n the core c u r r i c u l u m is revised. L i m i t a t i o n s of this study m a y restrict its usefulness in other settings and i n c l u d e a differing case m i x at 19:7 July 1990
other hospitals and a clerkship structure s u b s t a n t i a l l y different than that at A l b a n y Medical College. T h e basic m e t h o d of a n a l y z i n g a c l e r k s h i p ' s bedside exposure, however, is applicable to e m e r g e n c y m e d i c i n e clerkships at a n y location. Choosing a different c r i t e r i o n level w i l l o b v i o u s l y affect the n u m b e r of categories identified as satisfying the criterion. In a s i m i l a r f a s h i o n , m o d i f y i n g t h e 32 category definitions or changing the total n u m b e r of categories could alter the results. In addition, the student logs themselves m a y provide sources of error. W h i l e L i n k s et al s h o w e d s t u d e n t logs to be reasonably accurate w h e n c o m p a r e d w i t h f a c u l t y observation, l a x i t y or i n a c c u r a c y in c o m p l e t i n g the logs as well as having i n c o m p l e t e i n f o r m a t i o n available to the s t u d e n t (eg, final diagnoses) reduces the accuracy of the results. ~7 Examining t h e c o m p l e t e m e d i c a l record to validate the student's log entry m a y increase accuracy but could also have the undesirable side effect of distorting t h a t to w h i c h t h e s t u d e n t h a d a c t u a l l y been exposed. Using the information obtained from the case logs, several modificat i o n s h a v e b e e n p l a n n e d for t h e clerkship. Students w i l l be encouraged to see a m i n i m u m of one each of c e r t a i n p a t i e n t s . T h e y w i l l b e given a sheet listing the seven clinical categories (Figure 1). W h e n e v e r a p a t i e n t w i t h one of the problems on the list is seen, the student will n o t e it and t h e n discuss the patient at t h e bedside w i t h the attending physician. A guide listing the differential diagnoses and i m p o r t a n t p o i n t s is provided to the s t u d e n t and f a c u l t y to facilitate discussion. As a r e s u l t of a n a l y z i n g the students' case distribution, a decrease in lecture and conference t i m e spent on selected categories has been achieved for those clinical areas where bedside teaching is predictable. This has allowed an increase in the n u m b e r of t o p i c s c o v e r e d in d i d a c t i c s e s s i o n s w i t h o u t increasing the t i m e assigned t h e s e sessions. Thus, t h e c o n t e n t , n o t j u s t the format, of t h e d i d a c t i c sessions has been adjusted to reflect a c o n s i s t e n t level of bedside teaching. Total clinical hours and reading assignments from standard t e x t b o o k s r e m a i n unchanged. However, a n e w c a s e - o r i e n t e d t e x t for m e d i c a l stud e n t s is c u r r e n t l y u n d e r d e v e l o p Annals of Emergency Medicine
ment. This text, modified after t h a t b y Platt, 18 w i l l c o n t a i n all the elem e n t s in the ACEP/SAEM guidelines for u n d e r g r a d u a t e e m e r g e n c y m e d i cine education. The approximately 20% of s t u d e n t s w h o do n o t see a p a r t i c u l a r c l i n i c a l c a t e g o r y at t h e bedside can be directed to read a n d discuss the a p p r o p r i a t e case in t h e textbook. CONCLUSION The study of cases seen by all sen i o r m e d i c a l s t u d e n t s in a r e q u i r e d f o u r - w e e k c l e r k s h i p in e m e r g e n c y m e d i c i n e has allowed us to identify clinical case categories seen at a fieq u e n c y that m e e t s a p r e d e t e r m i n e d c r i t e r i o n . T h i s i n f o r m a t i o n has allowed us to p l a n modifications in t h e d i d a c t i c p o r t i o n of the c l e r k s h i p to better c o m p l e m e n t the learning t h a t occurs at the bedside. The authors thank Barbara Norton for her assistance in administrating the study and Rosemarie Lupoli for typing the manuscript.
REFERENCES
1. Society of Teachers of Emergency Medicine: Core content for undergraduate education in emergency medicine. Ann Emerg Med 1985;14: 474-476. 2. American College of Emergency Physicians: Guidelines for undergraduate education in emergency medicine. Ann Emerg Med 1987;16: 117-119. 3. Sanders AB, Criss E, Witzke D: Core content survey of undergraduate education in emergency medicine. Ann Emerg Med 1986;15:6-11. 4. Sanders AB, Criss E, Witzke D: Survey of undergraduate emergency medical education in the United States. Ann Emerg Med t986;15:1-5. 5. Sanders AB, Criss E, Witzke DB: Emergency medicine skills and topics in undergraduate education. Proc Annu Conf Res Med Educ 1985: 83-87. 6. Lunenfeld E, Levin M, Lazin R: Emergency core curriculum of the Beer Shiva medical school. Isr J Med Sci 1987;23:1038-1040. 7. Shesser R, Smith M, Kline P, et al: A cost effective emergency medicine clerkship. J Med Educ 1985;60:288-292. 8. Klausner JM, Rozin RR: Undergraduate eduk cation in emergency medicine and initial man agement of trauma casualties in Israel. Milit Med 1987;152:458-461. 9. Browns CG, Sanders AB, Gurley HT, et al: Curriculum for undergraduate education in emergency medicine. J Med Educ 1984;59: 427-429. I0. Kline P, Shesser R, Smith M, et al: Comparison of videotape instructional program with a traditional lecture series for medical student emergency medicine teaching. Ann Emerg Med 1986;15:16q8. 750/49
CASE DISTRIBUTIONS De Lorenzo, Mayer & Geehr
11. Munro JGC: Computer analysis of the student log diary: An aid in teaching of general practice and family medicine. Med Educ 1984; 18:75-79. 12. Hobbs J, Mongan P, Miller MD: A system for assessing clerkship experience using a logbook and microcomputers. Faro Med 1987;19: 133-136. 13. Shesser R, Smith M, Kline P, et al: A stu-
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Annals of Emergency Medicine
16. Niland-Weiss J, Duda M, Dreskin M, et al: Computerized evaluation of clinical experience in the training of health professionals. I Allied Health 1985;14:255-266. 17. Links P8, Foley F, Feltham R: The educational value of student encounter logs in a psychiatry clerkship. Med Teach 1988;10:33-40. 18. Platt FW: Case studies in Emergency Medicine. Boston, Little, Brown and Co, 1974.
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