The training of house officers in the emergency department

J O U R N A L OF T H E A M E R I C A N COLLEGE OF E M E R G E N C Y P H YSICIA N S

OR~IGINAL CON TRIBU TIONS

November • December 1973 Volume 2, Number 6

The Training of House Officers in the Emergency Department Leon J. Taubenhaus, MD, MPH*

New York, New York

The training of residents and Interns In the Emergency Department has been ~ergely a hit-or-miss matter In most teaching hospitals, according to the results ofa study conducted among 467 university-affiliated hospitals. Of the 118 Institutions which responded to the survey questionnaire, there was little com,~onallty of training programs for house staff In the Emergency Department. Most Interns and residents enter the Emergency Department with little medical school training In the field and find, In the majority of cases, a poorly organized training experience. The study shows that even In hospitals having full-time emergency physicians on duty In the ED, the supervision and review of house staff was not placed In the emergency physicians' control In one-third of the hospitals. The difficulty of providing a worthwhile learning experience without Ihe ability of controlling the teaching environment clearly spells out the need for emergency services to achieve departmental status. Although interns and residents have served in hospital emergency facilities for a number of decades, it is 0nly recently that serious attention has been paid to the educational aspect of the emergency department. Even in hospitals in which service in Ihe emergency department is considered an important facet of house officer education, little thought has been given to the specific educational methodology. In 1971 the American College of Emergency Physicians established a commission on teaching hospitals to emphasize the importance of improving the education of house of~icers as they rotated through the emergency department. The commis-

*Director of Community Health Services, Beekman Downtown Hospital, New York, ~nd Lecturer, Columbia UniversRy School of Public Health and Administrative teedicine. 4ddress for reprints: Leon J. Taubenhaus, teD, Beekman Downtown Hospital, 170 William Street, New York, New York 10038.

Nov/Dec

sion became a committee in 1972 and in 1973 it became a sub-committee of the College's graduate education committee. These changes in the committee's organization occurred in response to an increasing awareness of the relationship of this segment of postgraduate education in emergency medicine to other segments of medical education. As the committee began its examination of the training of house ofricers, it quickly learned that it was largely a hit-or-miss affair. Training in one institution had little or no relationship to training in another. There had been no attempt at a national standard to evatuate the level or quality of the training. There was no documentation of who did the training, of how it was done, or of what were the problems encountered in carrying it out. In 1972, as a first step, the committee undertook a survey of teaching hospitals to document and develop a profile of teaching hospital emergency department organization and teaching methods.

This report presents the results of that survey.

METHODS

AND RESULTS

A questionnaire was developed and mailed to 467 university affiliated teaching hospitals. Replies were received from 118 hospitals (25%). Of those responding, 102 hospitals (86%) rotated interns, residents, or both, through their emergency departments. Based on the limited returns, universities appear to affiliate more frequently with hospitals with large emergency department patient loads (Table 1).

Table 1 Annual Patient Visits to Teaching Hospital Emergency Departments Number of Visits Lessthan 18,000 18,000--29,999 30,000--49,999 34,000 Total

HospitaLs Replying Number Percent 28 23 33 34 118

24 19 28 29 100

H o u s e Staff C o v e r a g e Of the 118 hospitals describing their pattern of house staff coverage (Table 2), 14% had no house staff on duty in their emergency department while 59% utilized both interns and residents. Intern and resident staff proved the mostprevalent pattern in university hospitals of all sizes though large emergency departments utilized interns and residents almost twice

Journal of the American College of Emergency Physicians

Page 401

THE TRAINING

OF HOUSE OFFICERS

as often as small departments. The use o f h o u s e staff for p h y s i c i a n c o v e r a g e i n c r e a s e d as n e e d for d e p a r t m e n t staff increased. It was c o m m o n to find a large d e p a r t m e n t e m p l o y i n g interns and residents for p a t i e n t s e r v i c e s . In the s m a l l e s t facilities, the absence of house staff w a s not unusual.

Attending Staff Coverage A definite pattern of e m e r g e n c y d e p a r t m e n t attending physician staffing related to patient load was not clear (Table 3). The e m p l o y m e n t exclusively of full t i m e attending physicians was p r e d o m i n a n t in most hospitals studied except for those having m o r e than 50,000 patient visits per year. At the same time, as many as 1,4% of the e m e r g e n c y d e p a r t ments used no assigned attending physicians. No attending staff was utilized in one-fifth of both the largest and the smallest departments. There a p p e a r e d to be no relationship in teaching hospitals between the presence of an attending physician and the p r e s e n c e o r absence of house staff. T h e r e were, however, house staff always assigned to the e m e r gency d e p a r t m e n t when no attending physician was on duty (Table 4).

Table 2 House Staff Coverage According to Annual Number of Emergency Department Visits Number of Hospitals by Annual Patient Load Type of House Staff Coverage Only Interns Only Residents Interns & Residents Neither Interns nor Residents Total (100%)

Less than 18,000 No. %

18,00029,999 No. %

3 7 12

3 6 10

6

5

3 12

3 10

6 28

5 24

2

2

5

4

23

20

33

27

t

30,00049,999 No. %

More than 50,000 No. %

Total No.

5 4 19

3 1 27

3 1 22

17 15 70

1 1 5

3

3

16

1

34

39

4 3 16

118 1-~

Table 3 Attending Staff Pattern of Emergency Departments by Patient Load Attending E.D. Staffing Pattern Full-Time Only Part-Time Only Both No ED Attending Total

Annual Patient Load 18,00029,999 No. %

<18,000 No. % 15 3 4

14 3 4

9 3 5

8 3 5

6

6

1

1

28

27

18

17

30,00049,999 No. %

50,000 + No. %

Total No. %

17 5 1

15 5 1

11 6 13

52 17 23

49 16 21

8

7

15

14

23

21

38

35

10 6 12

107 100

Table 4 Relationship of House Staff Coverage to Attending Coverage

Compensation of Attendlngs Salaried attending physicians were employed in t h e e m e r g e n c y d e p a r t m e n t s in 65% of the hospitals w h i l e attending physicians on fee-forservice w e r e found in 24%. The rest of the hospitals, if there was c o m p e n sation at all, used s o m e different m e t h o d . Thus teaching hospitals differ m o r e in the w a y they pay attending physicians than do other 6bspitals. This may reflect the utilization of e m e r g e n c y p h y s i c i a n s as much for teaching as for patient care.

Indirect Supervision and Review

Coverage

Full-Time Only Part-Time Only I Full & Part Timq No.

%

No.

%

Intern Only Resident Only Both No House Staff

8

8

2

2

6 26 9

6 26 9

14

14

Total

49

49

16

16

None

No.

%

No.

%

3 4 12 2

3 4 12 2

2 2 10

2 2 10

21

21

14

14

Table 5 Responsibility of House Officer to Emergency Department Physician in Relation to Emergency Department Patient Load Number of Patient Visits (99 Hospitals)

The indirect m e t h o d s of house staff supervision s h o w e d m a r k e d variation. Ninety-three hospitals reviewed e m e r g e n c y records. In one-third of these, all e m e r g e n c y records were reviewed. In t w o - t h i r d s the records w e r e s a m p l e d , but the s a m p l i n g m e t h o d s varied. S o m e e m p l o y e d ranPage 402

Type of Attending Staff Coverage (100 Hospitals) Type of House Staff

House Staff Responsible to E.D. Physician

<18,000 No. %

Yes No

8

8

10

Total

18

30,00049,999

18,00029,999 No. %

No.

%

No.

%

No.

10

14 5

14 5

20 9

20 9

25 8

25 8

67 32

18

19

19

29

29

33

33

99 100

J o u r n a l of the A m e r i c a n C o l l e g e of E m e r g e n c y P h y s i c i a n s

50,000 +

Total

Nov/Dec

67 33

1913

j0rnized sampling. Others selected ,ecords on the basis of special Griteriasuch as type or seriousness of ~sse-In eight hospitals, no record fBview took place. Sixty-one out of 103hospitals (59%) held supervisory eaching rounds in the emergency ~epartment and 54 out of 105 (51%) ~eldcase conferences. In 73 of these i0spitals (70%) admissions to the ~0spital were followed up. All but five ~t 108 emergency departments ~lternpted to follow up on complaints.

supervision of House Staff In 71 of the 88 hospitals specifying ~nattending physician on duty (81%), !heattending provided direct supervisi0n over the house officer. Both the ~0use officer's evaluation and his lreatment of the patient were usually supervised. In only 38% of the ~0spitalswas this supervision providedaround the clock. When asked if the senior resident on duty performed any supervisory r01e, 91 hospitals replied. SeventyIw0 of these (79%) replied affirm~lively. In 63% this supervision was ona 24 hour a day basis.

Patient Care Responsibility Each hospital was asked if tf house staff attended to all patler .s. One hundred and five hospi als replied. Of these, 63 said all pat ~nts wereseen by the house staff (6e ¢). In 42 hospitals (40%), the hous~ staff saw only some of the patif.lts. In ~hose institutions in which ho se staff responsibility for patient r ~re was limited, in about one-her of the hospitals the patients se acted for Such care were determir .~d by the degree of severity of .le illness. Selection for house staff ;xamination ~as on the basis of sic ,,cific symptoms in the other half.

Responsibility for House Officers Not all house officers were directly ~'esponsible to the a t t e n d i n g emergency physician (Table 5). ExCept in t h e s m a l l e m e r g e n c y departments, in three out of four responding hospitals, the attending emergency physician controlled the Nov/Dec

house officer under him. In the small emergency facility, less than half the institutions assigned house officer r e s p o n s i b i l i t y to the a t t e n d i n g emergency physician. It made little or no difference whether the emergency physician was full time or part time.

hospitals in the education of their house staff. O n e - f o u r t h of the h o s p i t a l s p r e p a r e d t h e i r own manuals. Surprisingly, one-eighth of the hospitals used neither text books nor manuals to train their house staff.

Departmental Status and Control

Emergency medicine is becoming a major segment of the medical care spectrum. A growing number of services are demanded by the public who turn increasingly to the emergency department for episodic care. In many hospitals more people are seen annually in the emergency department than in any other section of the institution.

Table 6 indicates the departmental s t a t u s of u n i v e r s i t y a f f i l i a t e d emergency services. Two-thirds did not have departmental status. Of these, the largest number were part of the department of surgery. This is obviously a result of the historical development of hospital emergency services and reflects the days when emergency facilities were casualty stations. Today, the emergency d e p a r t m e n t is actually more a medical than a surgical service. If one looks at the cases requiring the mature judgment of a physician, the case load of any emergency department is overwhelmingly medical or pediatric. Yet only 14 out of 62 emergency departments were subordinate to the department of medicine and only one to a department of pediatrics. Eleven departments were part of the ambulatory care service.

Training Materials Three-fourths of the hospitals used text books or manuals of other

Table 6 Oepartmental Status of Emergency Service Emergency Service Has Departmental Status

39

Emergency Service Does Not Have Departmental Status 62 Emergency Department is part of following departments: Surgery Medicine Ambulatory Care Outpatient Service General Practice Nursing Pediatrics Administration

17 14 11 10 5 3 1 1

DISCUSSION

SUMMARY In spite of the increasing import a n c e of e m e r g e n c y s e r v i c e s , emergency medicine is one of the fields most neglected in medical education. In medical schools few if any students are exposed even to first aid training. When they receive their medical degrees and enter internships and residency programs they are thrown into the emergency department, often with little or no supervision or training for their role. Frequently they receive more instruction in the recognition, understanding, and treatment of rare and interesting conditions, never to be seen in a lifetime of practice, than they do in the emergency life support skills required in their subsequent daily rounds. In seeking information on the training of interns and residents in emergency medicine, questionnaires were sent to 467 university affiliated hospitals. Both the number and nature of the responses were not encouraging. There was little agreement or organization in the methods by which the the knowledge and skills of emergency medicine are taught to house staff. A number of reasons may account for this: (1) lack of interest in the subject by the power structure of medical education, (2) outdated but traditional neglect of the educational value of an ambulatory care setting, and (3) reluctance of inpatient chiefs to relinquish power.

Journal of the American College of Emergency Physicians

Page 403

THE TRAINING OF HOUSE OFFICERS

The presence of a full or part time emergency physician in the department does not insure adequate supervision or teaching of assigned house staff. Even where there were attending emergency physicians on duty, establishment rigidity or indifference prevented him from performing his optimal role as an educator. From a third to half of the teaching hospitals surveyed did not take advantage of the full teaching potential of the attending emergency physician. In many, he was denied control of the house staff. The administrative structure of the emergency department, particularly the relationship of the department status of the emergency facility to the responsibility for the house staff de!egated to the emergency physician, is significant here. It seems obvious that the educational and supervisorial effectiveness of the emergency physician is minimized if he does not have direct responsibility for the education of the house staff serving under him. Most of the emergency services were not allowed departmental status. When the emergency service was subservient to an inpatient clinical service, too often the house officer was responsible to his clinical inpatient chief during his tour of duty in the emergency facility. This leads to a significant shift in the direction of educational interests and priorities. Emergency medicine is a broad bas-

Page 404

ed, multi-disciplined, specialty. The numerous facets of the educational demands thus created are not generally encompassed by s p e c i a l i s t s whose e x p e r t i s e is directed along traditional specialty lines. When the emergency facility does not have independent departmental status, it may best fit into the ambulatory care department. Here it will not be crushed in the power struggle between the traditional clinical services. This is true educationally as well as administratively. Five of the surveyed institutions placed the emergency service under the family practice department. There is some rationale for this arrangement in hospitals where the department of family practice is a major influence. The placing of an emergency service under a department of nursing or administration is absurd in a teaching institution. This occurred in four instances in our survey. One can only assume that in these academic institutions the teaching of emergency medicine to future physicians has a zero priority. The negative aspects of these findings re-enforce the firm contention of the American College of Emergency Physicians that an emergency service should have departmental status. This strengthens its effectiveness in its relations to inpatient or clinical services in the traditional specialties. Further data are required to shed

light on emergnecy services that ar~ part of ambulatory care or communit~ health units. Such relations may ~till allow them adequate administrati~ freedom because of common goalu which would appear to present no in. terdisciplinary conflicts. Furthermore an ambulatory care department, like an emergency department, als~ receives house staff from the various unidisciplinary training programs. This study of university affiliated emergency department house staff training programs in emergency medicine indicates that, although there has been some progress, the teaching of emergency medicine in these institutions has far to go. The basis of difficulties in educational programs appears to be the uni. disciplinary structure of medical education and its influence on the ad. ministrative structure of hospital emergency facilities. Only when the emergency department is freed from its dependence on services whose primary orientation is to the inpatienl can education for emergency medicine meet its potential. The public has already recognized the ira. portance of emergency medicine. Medical education must meet this challenge. The means are available, but administrative changes in both hospitals and medical schools are easential. While slow to come, the growing interest in sound emergency medical education cannot help but strengthen the forces for change. •

Journal of the American College of Emergency Physicians

Nov/Dec 191s