Marcel is a fourth year EM resident who is really coming into his own in the ED. For the most part, the medical aspects of being an emergency physician now come naturally to him. He quickly diagnoses complex patients, he knows what key investigations to order, and has a savvy know-how when speaking with consultants. As part of his self-tracking of his progress, he has been measuring the numbers of patients he sees on an average shift. Although he sees more patients per shift than he did a year ago, Marcel is concerned that his numbers have plateaued and feels “slow” compared to his peers. He wonders how he might improve his ED efficiency.
Being an EM resident has so many challenges; not least of which is learning to run a department and efficiently handle surges in patient volumes. This Feature Educational Innovation (FEI) was originally posted by the CAEP EWG FEI Team on February 20, 2015 and asks the clinical question, “Can we implement a specific rotation on ED efficiency for senior residents?” A PDF version is available here. A CAEP cast is available here.
Description of the Innovation
Emergency medicine programs should generate physicians with the competency to practice in urban academic centres. These centres are defined by high and unpredictable volumes and by the obligation, despite the flow, to ensure the safety of patients and manage multiple competing priorities, such as teaching. The focus is on the supervised evaluation and the identification/correction of conditions that may threaten the security of individuals during their stay in the emergency unit.
These aspects require excellent leadership skills and involve all CanMEDS roles. They are among the most difficult aspects to teach in emergency medicine because of the required integration of a number of skills, and also because: 1) several rotations during training favour a different model: a pattern in internal medicine where residents must develop differential diagnoses, as well as comprehensive investigative and treatment plans for which they have more time than is usually available in actual emergency medicine; 2) in emergency medicine rotations, staff physicians tend to protect the residents, even if they are seniors, and not leave them completely alone with the more critical and/or complex situations (i.e., if they are overwhelmed, they will get some help, whereas in their own practice residents will have to deal with the situation on their own). Also, concerns for patient safety will tend to induce an intervention that will deprive the residents with an opportunity to acquire important skills for their future practice.
In this context, the transition to actual medical practice can prove difficult for residents who have not acquired these skills through specific and more often personal efforts. Some will not succeed and will keep yielding sub-optimal productivity, which may lead to personal dissatisfaction and/or strain their relationship with colleagues.
As there is no specific training to help residents acquire this competency, the program committee has created an optional rotation for senior residents to help them acquire skills in the safe management of high patient volumes in association with competing priorities: a rotation in efficient emergency medicine. It consists of 15 sessions and structured activities, with the main objective to develop skills where the residents can be more efficient clinicians in the overall management of the emergency unit.
The teaching methods are: 1) supervision by direct observation; 2) reverse supervision; 3) supervision by physicians who are recognized by their peers as having the targeted skills (role models) and are able to provide longitudinal monitoring and daily progress assessments; 4) gradual to full takeover of the unit; 5) shifts covering “mistakes” where the supervisor and the resident rate potential or actual errors and discuss security.
So far, two residents chose this rotation and pursued it with very positive evaluations; therefore three other residents will be taking this rotation next year.
For seasoned clinicians, what are your top tips for improving efficiency on your ED shifts? For learners, what are some ways you have learned to boost your patient volumes?
More About the CAEP FEI
This post was originally authored for the Canadian Association of Emergency Physicians (CAEP) Feature Educational Innovations project sponsored by the CAEP Academic Section’s Education Working Group and edited by Drs. Teresa Chan and Julien Poitras. CAEP members receive FEI each month in the CAEP Communiqué. CanadiEM will be reposting some of these summaries, along with a case/contextualizing concept to highlight some recent medical education literature that is relevant to our nation’s teachers. [bg_faq_end]
Sebastien Maire is Associate Clinical Professor at Université Laval. He is currently Program Director of the Laval Emergency Medicine Program and has also served as the medical director of the regional EMS system.
Julien Poitras is Associate Professor of Emergency Medicine and Associate Dean at Université Laval. His interests include hyperbaric and diving medicine and is actively involved with the CAEP Academic Section.
Daniel Ting is an Emergency Physician and Clinical Assistant Professor at the University of British Columbia, based in Vancouver. He is the Editor-in-Chief of CanadiEM and a Decision Editor at the Canadian Journal of Emergency Medicine. He completed the CanadiEM Digital Scholarship Fellowship in 2017-18. No conflicts of interest (COI).