Effects of External Forces on Emergency Medicine Residency Training in the US

Attachment A

Introduction

Our nation’s emergency departments (EDs) and their associated training programs in emergency medicine (EM) have seen tremendous change in the last decade. The reduction of capacity of our emergency services due to hospital closures has been significant- there are over 700 fewer hospital-based EDs than just 10 years ago.

In addition to the diminishing inpatient bed availability coupled with an increasing un/under-insured burden of patients to our health care system and newly arrived immigrant patient care needs, crowding in the inpatient service has lead to a breakdown in the ability of our patients to be promptly admitted to the hospital from the ED setting.

Graduate medical education (GME) reforms, increasing requirements for health care organizations imposed by federal and state statute, nursing shortages, medical school indebtedness, intermittent state and regional malpractice liability crises, technological advances with the attendant requirement for successful implementation, and advances in diagnostic testing required to successfully triage patients have further lengthened the stay of our ED patients.

Finally, the effect of terrorism here and abroad and our continued military interventions overseas with the attendant state-side effect have all combined to stress our EDs and adversely impact our efforts to train the next generation of emergency physicians.

This paper reviews these effects and on occasion suggests the manner in which the American College of Emergency Physicians (ACEP) may respond to these issues so important to our EDs and our GME programs.

Emergency Department (Institutional) Crowding

“ In the decade between 1993 and 2003, the US experienced a net loss of 703 hospitals, an 11 percent decline…during the same period the population of the US grew by 12 percent and hospital admissions by 13 percent…the outcome of these intersecting trends of falling capacity and rising use was inevitable. By 2001, 60 percent of US hospitals reported they were operating at or over capacity.” (IOM, p 38-9).

Since the release of the Institute of Medicine’s (IOM) report in June 2006, much attention in the literature and in the legislature has been given to the causes, measurement, and possible solutions of ED crowding.

One area of crowding research where the literature is sparse is the impact of crowding on medical education/residency training. In a June 2005 commentary in Academic Emergency Medicine, Heins et al., searched all 1999-2004 issues of Academic Emergency Medicine, Academic Medicine and Annals of Emergency Medicine and concluded that “investigation of the effect of ED crowding on educational outcomes requiring valid measures of clinical teaching and relevant educational outcomes has not been reported.” The authors concluded that “the optimal method to study the effect of ED crowding on education and training would be an extensive, multicenter study using validated measures of crowding, clinical teaching effectiveness, and learners’ educational outcomes. However, those measures are not yet available.”

One may assume that if, as the IOM report states, “overcrowding induces stress in providers and patients, and can lead to errors and impaired overall quality of care…” (IOM, p 4), there may be a negative external effect on resident medical education. Heins notes that in a study by Chisholm et al, “EM faculty directly observed resident care only 3.6 percent of the time and that total faculty-resident interaction time occupied 20 percent of the available time.”

Another supposition is that crowding would put further time constraints on the quantity (and possibly the quality) of faculty time, resulting in a negative impact on resident training. While these assumptions have yet to be proved, Heins suggests that in anticipation of crowding’s effect, “EM educators should begin to

develop the content and process for teaching residents and students about clinical productivity and management of crowded situations.”

Crowding and Disaster Preparedness

Specific training in enhancing productivity and the successful management of crowded EDs takes on special import when one considers recent events such as 9/11 and our nation’s wars abroad in Afghanistan and Iraq; the lack of ED surge capacity has been linked to concern for our nation’s security: “if we cannot take care of our emergency patients on a normal day, how will we manage a large-scale disaster?” (IOM, p 8)

The IOM report warned of the deficiency of training for ED workers in disaster preparedness: “In 2003…92 percent of hospitals trained their nursing staff in responding to at least one type of threat, but residents and interns received any such training at only 49 percent of hospitals.” (IOM, p 8) The report urged that to address the need for competency in disaster medicine, “all institutions responsible for the training, continuing education, and credentialing and certification of professionals involved in emergency care…incorporate disaster preparedness training into their curricula and competency criteria.” (IOM, p 9).

In a March 2007 Annals of Emergency Medicine article, Moye et al, examined the general trend of bioterrorism training in EM residencies since 9/11. The authors concluded that overall the prevalence of bioterrorism training among programs has increased dramatically over the last seven years.

However, the authors also discovered significant inter-program variability in the comprehensiveness of content and in the frequency, intensity, and manner of exposure (active, experiential vs passive learning technique). Seventy percent of programs presented topics only semiannually or less. Moye et al noted that the more experiential, intense programs tended to be better funded for training/research and concluded that “further support for residency training programs may ensure better preparedness of the receiving medical community at the hospital level.”

Such federal funding and support may be on the horizon. In October 2007, the White House issued a press release outlining Homeland Security Presidential Directive/HSPD-21; this directive mandated that within 180 days, the Secretary of Health and Human Services would establish within the Department of Health and Human Services (DHHS) an Office for Emergency Medical Care.

The Office is charged with addressing, “the full spectrum of issues that have an impact on care in hospital EDs.” One of the duties of the Office shall be to, “lead an enterprise to promote and fund research in emergency medicine and trauma health care.” This is in direct reference to the observation in the IOM report that, “only .05 percent of the National Institutes of Health (NIH) training grants awarded to medical schools goes to departments of EM – an average of only $51.66 per graduating resident. In contrast, internal medicine receives approximately $5,000.00 per graduating resident.” (IOM, p 12)

It appears the federal government is willing to make a considerable investment into disaster medicine preparedness --- the budget increased from $237 million in fiscal year 2000 to $9.6 billion in fiscal year 2006.” (NEJM 355; 1300)

Although few residents will ever be directly involved in a disaster, because of the publicity surrounding disaster preparedness, EM residency-trained physicians may find themselves behind the curve of public expectation regarding their training in disaster management. (Kaji, 865-870). The onus will be on individual programs to close the gap between resident knowledge and public expectation; this may require reallocation of time from other areas of core content. Given the comprehensive curricular requirements of EM residency programs it will be challenging to adequately prepare resident trainees for future management of the medical aspects of disaster.

Medical School Indebtedness

Steady increases in medical school tuition and living expenses for medical students have resulted in high levels of graduating student indebtedness, a matter of concern to the Association of American Medical Colleges (AAMC) and many specialty society organizations, including the American College of Emergency Physicians (ACEP), and to resident organizations, including the Emergency Medicine Residents' Association (EMRA).

In 2004, the AAMC noted that the average medical school debt for a graduating student was approximately $120,000, had doubled in just the last five years, and was rapidly rising. More importantly, the percentage of medical school expenses met by students in the form of loans, after taking in to account personal and family contributions, grants and scholarships, is rising even faster than the overall debt.

Though ACEP, the American Medical Association (AMA), the AAMC and other organizations are seeking assistance in the form of grants and loan forgiveness programs from a variety of sources, including state and local governmental entities, there is an unmet need for more assistance to medical students for their education.

Adverse effects of high medical student debt include less interest in pursuing primary care specialty training due to the perception (or actual) lesser remuneration with in those specialties, less willingness to pursue GME in specialties with longer training requirements, less incentive to pursue supplemental training while in or post-medical school in disciplines that lead to degrees such as a MBA, MPH, or other Masters programs, and less incentive to practice in rural or underserved population settings.

Hospital Patient Flow and Operations

Recently there has been a recognized need to educate both hospital administrators and medical staff on the nuances of ED patient flow. Specifically, it is now universally recognized that the number one cause of ED crowding and stagnant ED patient flow is boarding of admitted patients in the ED and inefficient hospital patient flow, respectively.

Both are “back end” hospital inpatient flow processes not under the control of emergency physicians. However, both hospital administrators and medial staff colleagues have been slow to embrace this reality. Rather, they continue to believe that ED crowding is a problem to be fixed by the ED itself, and that ED crowding is caused largely by overuse of the ED by non-urgent patients who shouldn’t be there.

EM residents work and train in hospital-based practices, and the viewpoints and philosophies of hospital administrators dramatically affect not only their training but their practice of EM. They can ill afford to be uninformed of erroneous administrative viewpoints and hospital ED-related operational issues. Back end hospital inpatient inefficiencies lead to ED crowding and inefficient ED patient flow, which subsequently leads to ED patients leaving the hospital without being seen and against medical advice, and to increased ambulance diversion. Besides the obvious patient safety issues involved, fewer patients are available to be seen in the ED, resulting in a poor educational experience for residents in training.

Many hospitals have only recently begun to address back end hospital patient flow inefficiencies. Residents need to be aware of, and participate in, solutions to the back end problems.

To decrease boarding of admitted patients in the ED, inpatient length of stay per medical specialty needs to be addressed. In many hospitals, the causes of excessive inpatient length of stay are multi-factorial and include poor inpatient bed management, inadequate housekeeping and inpatient nurse staffing, and delayed hospital and medical staff discharge practices. Hospitals must coordinate the discharge of their inpatients before noon, making more inpatient beds available to admitted ED patients in a timely manner.

In addition, there must be better scheduling of elective surgical patient admissions into the hospital. Studies have shown that the uneven influx of these patients earlier in the week is a prime contributor to hospitals exceeding their bed capacity.

Finally, when all other boarding solutions have failed, emergency physicians and EM residents also need to advocate for moving emergency patients who have been admitted to the hospital out of the ED to inpatient areas, such as inpatient hallways, conference rooms and solaria.

Only by better understanding these issues and solutions related to ED crowding will residents be able to help educate hospital administrators, and more importantly, their non-EM resident colleagues, and improve their educational environments in EDs.

While hospital back end issues are beyond the control of EM staff and physicians, ED “front end” operational processes such as patient arrival, triage and registration are more under the ED’s control.

However, ED front end inefficiencies can be equally detrimental to the EM resident educational experience. For example, lack of a bedside registration or triage policy that does not support bringing patients immediately to open ED beds can result in less patients being available for resident evaluations.

Similarly, residents and program directors need to weigh in on the educational pros and cons of novel triage initiatives such as first line orders, whereby emergency nurses are able to order radiographs and laboratory tests first on ED patients based on presenting symptoms. This triage process could usurp EM residents from learning this decision skill.

Moreover, with excessive waiting room times in many EDs, should EM residents and physicians now be staffing triage or waiting room teams that attempt to evaluate and process patients not in the ED but in either the triage office or waiting room?

These novel ED front end initiatives have the potential to profoundly affect the traditional EM resident educational experience as we strive for innovative ways to move patients more efficiently through the ED. Residents and program directors should not be bystanders but rather active participants as these new processes in the ED are being proposed and evaluated.

The ED Nursing Shortage

The need for trained nurses is rising as our population ages. More significantly, nursing training programs have failed to expand which has resulted in a significant current nursing shortage. Estimates of the rising future shortage range from 300-800,000 by the year 2020.

Currently this shortfall has been met, in part, with the influx of nurses trained overseas. Their training occurs in settings where the nursing curricula differ substantially from US nursing schools. They specifically lack training in emergency care because EM and specifically emergency nursing are not recognized specialties in these countries. These nurses are disproportionately serving in urban hospitals which are the most common setting for the training of US medical students and residents in GME programs. It is an axiom in medical education that all health care providers, including nursing staff, contribute to the educational experience of medical students and resident house staff. It follows that less experienced emergency nursing staff will adversely impact the quality of the education of residents and medical students.

In addition to the nursing shortage, hospital efforts to fully staff their EDs with full time nursing personnel is further impacted by the growth of non-hospital based agency nursing services. These nurses are essentially independent contractors who are called on very brief notice to shore up any short fall in nurse staffing on a given day. These nurses arrive unaware of the routine care guidelines specific to that institution and often are not experienced in working in a medical student or resident training setting.