Emergency Medicine Residency Infrastructure and Support

The Residency Office: A Hub of Activity and a Myriad of Relationships

The residency office interacts with multiple individuals and agencies in a complex environment (Figure 16.1). Some of these entities function as academic or administrative overseers (e.g., dean’s office, chair of the department, graduate medical education [GME] office), whereas others can be viewed as constituencies (e.g., the residents and the faculty). Because the residency office is accountable to so many parties whose objectives are often divergent, a program director must possess very strong interpersonal skills. He or she must be perceived as conciliatory and reasonable (someone people would naturally go to for guidance during a conflict) to gain credibility and currency within the institution. It is necessary to be a leader and, at times, a follower as part of a larger GME community. The respect and support of those who provide oversight to the residency office are critical prerequisites for the success of a residency training program. Without which, it is impossible for the residency office to advocate for those things necessary to advance the program.

Figure 16.1 The myriad relationships of the residency office.

The residency office must also be resourced properly to achieve its goals. The workload of the residency has periods of greater intensity throughout the year (e.g., in interview and recruitment season and during the orientation of new residents) and periodically throughout the accreditation cycle (e.g., internal reviews, Residency Review Committee–Emergency Medicine [RRC-EM] site visits, or international equivalents). The department must have enough flexibility to devote extra resources during these times. Lack of administrative support for the faculty associated with the residency office is a common concern among program directors and, along with the resultant lack of academic productivity, has been cited as a negative influence on program director longevity. In a recent survey of program directors in EM, the most commonly cited problems associated with their position were inadequate protected time for scholarly activity, a lack of career/family balance, and insufficient time overall to do the job [1] (Table 16.1). This is particularly true in the international setting where EM education and EM systems are in their early stages of development, requiring the founding EM faculty to perform a tremendous amount of clinical and administrative duties, leaving very little time for proper residency attention and development.

Table 16.1 Most common concerns cited by program directors in emergency medicine.

^a Scale of 1–5. All other potential problems scored <3.

 Reproduced from [1] Beeson M, Gerson L, Weigand J, et al. Characteristics of emergency medicine program directors. Acad Emerg Med 2006; 13(2): 166–172, by permission of John Wiley and Sons Ltd.

Scheduling and Its Effect on Learning

Scheduling of residents and faculty has the potential to create a tremendous impact on education. Many parts of the world still allow excessive and potentially dangerously high working hours for residents and physicians in training. Although the Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations have done much to eliminate the exhausted resident from patient care areas in USA, less has been done to delineate and encourage scheduling strategies that can positively affect teaching and learning.

Fundamentally, teaching requires energy from both the learner and the teacher. Conflicting with this is the obvious reality of 24/7 care, and in EM, both residents and faculty must provide service throughout the night. Multiple authors have looked at circadian rhythm disruption in the workplace and have suggested techniques to minimize “night shift” effects, but few residencies have integrated these concepts into their schedule. Core sleep preservation (a fixed sleeping period) and forward phase shifting (e.g., a day-shift/evening-shift/night-shift sequence) both serve to decrease circadian rhythm disruption and improve energy levels for teaching and learning [2, 3].

Shift durations for both faculty and residents generally range between 8 and 12 h (the maximum allowed by the RRC-EM in USA). While residents may prefer 12-h shifts to maximize their days away from the hospital, it is likely that a shorter shift duration is more optimal for learning and ED throughput. Recent studies have shown that resident productivity declines reliably with accumulated time in the ED regardless of the level of training. By reducing shift duration from 12 to 8 or 9 h, more patients are seen per hour and there is an overall increase in number of patient encounters per year, thus providing more learning opportunities during the same period of residency training [4, 5]. In our program, faculty shifts are generally shorter than resident shifts, and they are staggered. We try to schedule the residency office faculty on a swing shift that overlaps evenly with two separate resident shifts. This provides an excellent opportunity to maximize the frequency of their exposure to all the residents (Figure 16.2).

Figure 16.2 A model for scheduling of faculty and residents.

Residency Program Culture and Conflicts

An eternal conflict exists between resident autonomy and patient safety. Although faculty members appreciate the need for residents to have sufficient autonomy to develop clinically, they often worry that too much autonomy will come at the expense of patient safety. Although these two ideals will always exist in some sort of dynamic equilibrium, they are not necessarily incompatible. A common complaint heard from residents about certain faculty members is that they tend to err on the side of “micromanaging” cases and can be inflexible about patient management. Faculty members should consider making changes to a resident’s management plan only if it is dangerous, allowing residents to practice in a safe, but not completely controlled, supervisory environment. This delicate balance must be accompanied by an atmosphere that allows residents to feel comfortable asking for help when they feel unsafe or not yet competent at a particular moment in time. To achieve this, we believe that a culture that minimizes authority gradients in the ED is most conducive.

Assurance of sufficient resident autonomy extends far beyond their relationship with individual faculty members. It is the responsibility of the residency office to provide an environment where residents are supervised but able to make autonomous clinical decisions and perform their procedures, especially during critical resuscitations. If the department of EM is newly founded or lacks sufficient influence at the institutional level, especially in a training institution with large training programs in surgery, anesthesiology, and critical care, it may be very difficult to create the environment necessary for this autonomy to exist. Nevertheless, ensuring patient care access and decision-making responsibility is absolutely critical to the success of the program.

The Core Competencies

Six core competencies were mandated to be integrated into the US residency training programs in 2001 as the first phase of the ACGME Outcome Project [6]. Although the eventual objective of the project is to improve the quality of GME through measurement of educational outcomes, the initial phase has served mostly to provide a common nomenclature for the process of evaluation. In fact, most of the instructional tools and assessment techniques that were subsequently described to address the six competencies were in use before the commencement of the Outcome Project. The six core competencies, as well as the tools used to teach them and assess them, are outlined in Table 16.2.

Table 16.2 Summary of teaching and assessment tools for each competency that is required by the Accreditation Council for Graduate Medical Education.

CD, compact disk; CORD, Council of Residency Directors; OSCE, objective structured clinical exams; ACGME, Accreditation Council for Graduate Medical Education; CAT, critically appraised topics; CQI, continuous quality improvement; M&M, morbidity and mortality; SDOT, standardized direct observation tool.

Reproduced from [6] Stahmer S, Ellison S, Jubanyik K, et al. Integrating the core competencies: proceedings from the 2005 Academic Assembly consortium. Acad Emerg Med 2007; 14(1): 80–94, by permission of John Wiley and Sons Ltd.

For most EM faculty not directly involved in residency administration, three of the six competencies—patient care, medical knowledge, and interpersonal skills and communication—are self-explanatory. The intent of the remaining three—professionalism, systems-based practice, and practice-based learning and improvement—is not as obvious. They are discussed in the subsequent sections. All six competencies have been defined specifically in relation to EM.

Professionalism

Professionalism appears to overlap with interpersonal and communications skills; however, specific skills and behaviors critical to the practice of EM underscore proficiency in this competency. Some can be assessed in the clinical setting, when observing the handling of patient care transfers (sign-out), during negotiation of ethical dilemmas, and during difficult patient encounters. Others can be evaluated outside the clinical realm, such as compliance with medical record keeping and the multiple, recurrent administrative requirements of residency training. In our program, a component of the professionalism evaluation is completed by the residency coordinator, who assigns a score to each resident. This score is based on the resident’s responsiveness to administrative queries from the residency office, integrity in shift trading, fulfillment of teaching responsibilities, timeliness, and overall reliability. Although some of this assessment is necessarily subjective, much of it is easily quantifiable with clear and consistent record keeping.

Practice-Based Learning and Improvement

Practice-based learning and improvement is the critical review of one’s clinical work and the growth that occurs as a result of that review. Activities related to evidence-based medicine (e.g., literature searches and journal clubs) as well as peer-review activities (e.g., chart reviews and quality assurance audits) fall under this competency. Perhaps, the most important process in practice-based learning for the emergency physician is patient follow-up. It is difficult to prevent recurrent mistakes and bad habits if one does not regularly follow-up with patients and their care providers. In USA, the RRC-EM specifically requires a formal process for documenting regular follow-up on a selection of patients seen in the ED. Although there are different ways of implementing this requirement, it is critical that follow-up occurs by some formal mechanism. Invariably, the information gleaned by following cases to their outcomes touches on other competencies, especially patient care, medical knowledge, and systems-based practice. We require a simple regular follow-up exercise on a selection of patients from different areas of the department (e.g., major trauma, fast track), including some who are admitted and others who are discharged home.

Systems-Based Practice

Systems-based practice has a very central meaning in EM. To be considered proficient in systems-based practice, a resident must “demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value” [7]. While this competency may play a secondary role to patient care in other specialties, in EM, expertise within various systems is easily as important as individual patient care. From the beginning to the end of each shift, emergency physicians operate within a set of complex, overlapping, and interconnected systems: the prehospital system; trauma, cardiovascular, neurologic, and other specialized care systems; and the institution’s on-call specialty consultation, diversion, and surge capacity systems. Decisions made in the care of an individual patient affect the care of all other patients in the department. Every decision to pursue a specific assessment or treatment plan is done so within the context of prioritization and by the differential application of a finite set of resources to all patients in the department. Moreover, safe and efficient disposition from the ED requires the highest level of sophistication and understanding of the entire health care system beyond the ED—its inpatient and outpatient components.

Although various tools have been proposed for the teaching and evaluation of systems-based practice, none, in our view, is as important as real-time assessment and direct observation within the clinical area. This can be done by multiple evaluators: faculty, peers and colleagues, nursing and ancillary staff, and also the residents themselves. Supervising faculty in our program are asked to assess EM residents during clinical shifts in real time with respect to their ability to efficiently multitask, delegate, supervise, and interface with the many individuals who and systems that they encounter. They are also asked to comment on the cost-effectiveness of their utilization of departmental resources.

Paradigms for Teaching Residents

As Sir William Osler said more than 100 years ago, “take [the student] from the lecture room, take him from the amphitheatre … put him in the outpatient department, put him on the wards … no teaching [should occur] without a patient for a text, and the best is that taught by the patient himself” [14]. “Educational nirvana” occurs when a resident with the appropriate foundation encounters a patient or a scenario that he or she has not encountered before, preferably requiring a treatment or procedure that he or she has not yet performed, with an enthusiastic faculty member acting as a catalyst in the learning process (Figure 16.3). As a catalyst, the faculty member should allow the patient to do the teaching whenever possible, as Osler taught, but he or she can enhance the process by reinforcing the key features of the presentation and/or clinical decision making that need to be recognized for future encounters.

Figure 16.3 The residency education triangle.

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