1. How to Run an Emergency Medicine Residency Program Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, U.S.A.

2. My Background for This Lecture Program Director for proposed Penn State University E.M. Residency and wrote the Program Information Form for this in 1991 Helped develop Joint E.M. Residency Program (York Hospital – Penn State Hershey) and served as Associate Director of this 1994 – 2003 Associate Director of the independent Penn State Hershey E.M. Program 2004 – 2007 C.O.R.D. member 1994 - 2007

3. General Benefits of Having Specialty Residency Training in Emergency Medicine (E.M.)  Provides core of specialists to staff emergency departments (E.D.'s).  Provides physician leadership : –E.D. administrators or managers –Prehospital care system directors –Coordinate outpatient & inpatient care  Ensures quality, depth, and uniformity of training for emergency care.  Teaching E.M. residents can provide a lot of career satisfaction, and can be fun !

4. Essential Ingredients for a Successful E.M. Residency Program. An enthusiastic, energetic, career-dedicated, knowledgeable, and clinically competent Program Director A cooperative and supportive Department Director and Core Faculty An energetic and supportive Program Coordinator Support from the hospital administrators and other clinical departments

5. Start-Up Sequence for a New E.M. Residency Program Obtain institutional support and initial financing. Find and hire an experienced Program Director. Put in place all the structural components (see the Accreditation Council for Graduate Medical Education web site www.acgme.org for the “Common Program Requirements” and the Residency Review Committee for E.M. Specific Program Requirements).www.acgme.org Fill out and submit the Program Information Form (PIF) to the ACGME. Be nice to the Residency Review Committee representatives when they arrive to inspect the proposed program.

6. . 1. There must be a single program director with authority and accountability for the operation of the program. The sponsoring institution’s GMEC must approve a change in program director. After approval, the program director must submit this change to the ACGME via the ADS. [As further specified by the Review Committee] 2. The program director should continue in his or her position for a length of time adequate to maintain continuity of leadership and program stability. 3. Qualifications of the program director must include: a) requisite specialty expertise and documented educational and administrative experience acceptable to the Review Committee; b) current certification in the specialty by the American Board of ________, or specialty qualifications that are judged to be acceptable by the Review Committee; and, c) current medical licensure and appropriate medical staff appointment. [As further specified by the Review Committee] 4. The program director must administer and maintain an educational environment conducive to educating the residents in each of the ACGME competency areas. The program director must: a) oversee and ensure the quality of didactic and clinical education in all institutions that participate in the program; b) approve a local director at each participating institution who is accountable for resident education; c) approve the selection of program faculty as appropriate; d) evaluate program faculty and approve the continued participation of program faculty based on evaluation; e) monitor resident supervision at all participating institutions; f) prepare and submit all information required and requested by the ACGME, Sample Text Lifted from the ACGME Web Site Document “Common Program Requirements” (an 81 page document)

7. Assistive Resources in Starting a New E.M. Residency The Society for Academic E.M. (S.A.E.M.) has a Residency Consultation Service (for a fee the Service will send an experienced reviewer to analyze the proposed program and its PIF). The Council of Residency Directors (C.O.R.D.) has helpful information on its web site (www.cordem.org) and at its several meetings each year (the Program Director(s) should be a member).www.cordem.org S.A.E.M. (www.saem.org) and A.C.E.P. (www.acep.org) and E.M.R.A. (www.emra.org) also have good reference information.www.saem.orgwww.acep.orgwww.emra.org

8. General E.M. Residency Program Requirements Program must be at least 36 months in duration (can be PGY 1,2,3 or PGY 2,3,4 or PGY 1,2,3,4 formats). Should teach the skills, knowledge, and behaviors of E.M. practice. At residency completion, graduates should be able to practice E.M., add new skills and knowledge, and monitor their own well being.

9. Faculty Requirements for U.S. E.M. Residency Programs  Department chief must have : –E.M. board certification, administrative & clinical E.M. experience, academic achievement, involvement in medical organizations, same authority as other institutional chiefs.  Program Director must have : –E.M. board certification, > 3 years experience, be clinically active, be scholarly active, and have at least 50 % “protected time” to run the residency, & full authority over the program.  Teaching Faculty must have : –At least one per every 3 residents, 25 % of time protected for academic activities, some must do research, most must be E.M. board certified, must provide 24 hour a day E.D. coverage, and there must be a faculty development program.

10. Facility Requirements for U.S. E.M. Residency Programs  Patient census > 30,000 (total) per year.  Pediatric census 15 % or 4 months full time equivalent.  Critically ill / injured patients : at least 3 % of census or > 1000 per year.  At least 2000 patient encounters per resident per year.  Accredited medicine & surgery residencies must be at same clinical site.  Must have offices and program support space for faculty & residents.  Stat lab results should be available in < 1 hour.  Must have at least 5 hours per week didactic instruction by faculty.

11. Requirements for E.M. Residency Sponsoring Institutions Medical school affiliation desirable Sponsors must be committed to graduate medical education Long term financial commitment to the program is needed Affiliation agreement needed for each hospital where residents rotate

12. Additional E.M. Residency Sponsoring Institutions Requirements One hospital must be primary ; the Program Director must be based here. Reasons to include multiple hospitals should be clear. Multiple hospitals should not be geographically distant. Residents must participate in conferences even when at different hospitals. One faculty must be responsible for resident activities in each institution.

13. Requirements for Residents in U.S. E.M. Training Programs  May not work > 12 hours continuously in E.D.  May not have more than 60 hours per week total clinical time  May not work > 72 hours per week including on-call & conferences  Must have at least one day off in every 7 days  Must be relieved of clinical duties sufficient to attend at least 70 % of scheduled conferences  > 50 % of rotations & clinical time must be in E.D.  Must keep a procedure logbook  Must have followup information on admitted patients  May not be supervised by resident physicians from specialties other than E.M. when in the E.D.

14. General Structure of U.S. E.M. Residency Programs (cont.)  > 50 % of time (> 18 months) in program must be in the E.D.  Important "off-service" rotations : –Critical care units (pediatric, medical, surgical) : at least two months required –Trauma surgery –Pediatrics –Orthopedics –Anesthesia –Medicine / cardiology

15. Non-E.D. E.M. Rotations Usually Included in E.M. Residency Programs  Toxicology  Pre-hospital care  Aeromedical care (flying usually optional for residents)  Research  1 to 2 months of electives

16. E.M. Residency Program Director Responsibilities Develop goals of program in writing Select new residents Participate in faculty evaluation Ensure appropriate resident supervision Regularly evaluate the residents in writing Handle resident grievances Manage resident stress and wellness Make sure the program continues to meet the ACGME RRC-EM requirements

17. E.M. Residency Educational Program Requirements Conferences for residents –At least 5 hours weekly of planned conference developed by the EM program –Should include : curriculum, Morbidity and Mortality, journal review, administrative seminars, and research methods –Faculty should attend conferences also

18. E.M. Residency Educational Program Requirements (cont.) Research and scholarly activity –Journal clubs and research conferences –Professional and scientific meetings –Participate in research or scholarly activity Most programs require completion of a research project and an “educational” project –Learn basic research methodology

19. E.M. Residency Educational Program Requirements (cont.) Resident physician Wellness –One of the main Program Director responsibilities –Balance personal and professional activities –Provide support for stress, circadian rhythms, and substance abuse problems –Residents must be pre-notified as to how to access support services

20. Helpful Specific E.M. Faculty Roles to Consider Assistant or Associate Program Directors (obviously at least one designee is needed to run the Program when the Director is not present ; Programs with more than 18 residents often utilize one Assistant or Associate per each additional 8 to 10 residents). Medical Student Rotation Director. Director for “Off-Service” residents in the E.D.

21. Additional Helpful E.M. Faculty Role Assignments to Consider Research Director Didactic Conference Series Director E.M.S. Director Quality Improvement Programs Director Official Liaisons to other clinical departments Assigning each resident to a Core Faculty person to act as the primary “counselor” for each resident

22. Additional E.M. Department Choices to Consider Should involve conjoint decision by the Dept. Director and the Program Director : –Medical student rotation(s) in the E.D. –“Off-Service” resident rotations in the E.D. –Having additional “Combined” residencies (i.e., E.M.-I.M., E.M.-Peds, etc.) –Having postgraduate fellowship(s) ( see next slide)

23. Choices for E.M. Fellowship Training Programs (following E.M. residency)  Emergency Medical Services (Prehospital care) : 1 to 2 years  Toxicology : 2 years (separate subspecialty certification)  Pediatric E.M. : 2 years  E.M. Research : 1 to 2 years  E.M. Administration : 1 year  E.M. Education : 1 year  Hyperbaric Medicine : 1 year  Sports Medicine : 1 to 2 years  Critical Care (Intensive Care) Medicine : 1 to 2 years  Aeromedical Care : 1 year  International E.M. : 1 to 2 years (may include obtaining an M.P.H. degree) Dedicated E.M. faculty director(s) needed for any of these

24. E.M. Program Director Options for Interviewing Resident Candidates ? Who performs initial application screening to decide on interview invitations ? Use limited number of faculty to do interviews or all faculty as available –? Have E.M. residents also interview ? Have interviews on “E.M. conference day” or other days ? Conduct the initial interview(s) in “blinded” mode ? What type of rank scoring system to use

25. Suggested Rank Order of Items to Consider in Ranking E.M. Residency Applicants 4th year E.M. clinical rotation(s) grade(s) Other clinical rotations grades Letters of recommendation Interview Personal statement Board scores Preclinical course grades Use of a combined numerical scoring system rating each of these items, with additional point scores for research or other unusual items, has proved useful for many Programs

26. The Extremely Important Position of E.M. Residency Program Coordinator The “right hand person” for the Program Director Success of the residency may depend almost as much on this person as on the Program Director Responsible for office components of the Program, to include : –Resident candidate interviewing –Resident, faculty, and Program evaluations –Resident procedure lists and test results files

27. The Six General Competencies the American Board of Medical Specialties Has Tasked All Specialties to Evaluate ƒPatient care ƒMedical knowledge ƒPractice-based learning & improvement ƒInterpersonal & communication skills ƒProfessionalism ƒSystems-based practice So the Evaluation(s) of residents’ and students’ clinical performance should be linked to these 6 items

28. Example July Orientation for E.M. R1’s in the Penn State Hershey Program 10 E.D. shifts 25 hours of didactics 26 hours of lab experience –Live animal procedure lab –Casting lab –Mannequin Simulation Labs –Ultrasound course –Slit lamp lab –Epistaxis control lab Life Lion Helicopter Fly - Along 1 to 2 days “Nurse for a Day” in the E.D.

29. Education / Scholastic Endeavour Requirements of the Penn State Hershey E.M. Program Project required for graduation –Original Research or Evidence Based Medicine review –Presented at research conference in June Supervised by predesignated faculty Presentations at regional or national conferences departmentally funded

30. Sample Rotation Schedule for the Penn State Hershey E.M. Program EM-1EM-2EM-3 4 mo. EM6 mo. EM4½ mo. EM Anesthesia2 mo. Community ED (HH)1½ mo. Administrative EM Internal MedicineSICU2 mo. Community ED (HH) CardiologyToxicology (HH)Trauma / General Surgery MICUEMSPICU Ob-Gyn (HH)OrthopedicsSelective Trauma / General SurgeryElective Pediatric Surgery Pediatrics (HH = “Harrisburg Hospital”, an affiliated local hospital)

31. Sample E.M. Resident Work Schedule in the Penn State Program 9 hour shifts (overlapping with next shift starting at hour 8) EM-1 : 23 shifts (48 hours / week) EM-2 : 22 shifts (46 hours / week) EM-3 : 21 shifts (44 hours / week) 4 months with call intern year 2 months with call 2 nd year 2 months with call 3 rd year

32. Sample Evaluation Scheme Used in the Penn State Program Annual review with Program Director Quarterly meeting with faculty advisor –Quarterly emergency faculty consensus evaluations –Off-service evaluations –Direct observation forms –Chart reviews –Procedure logs –Follow-up logs –Quiz scores –Research project progress

33. The American Board of E.M. (A.B.E.M.) In-Training Exam ƒGiven once per year (February) to all E.M. residents at their residency site ƒSimilar in length and content to the A.B.E.M. certification exam ƒHelps prepare residents for the certification exam ƒAllows Program Directors to identify areas of knowledge deficit in their residents which may then alter the residency curriculum, and allows comparison to other residencies

34. Benefits of Training Other Specialty Residents in E.M.  Allows ability & confidence in managing basic emergencies.  Familiarizes them with E.D. operations and needs.  Improves working relationship with E.M. faculty & E.M. residents.  Allows them to learn cost-effective use of ancillary tests.  Provides an educational service to their “home” departments (can be considered “educational payback” for their departments having E.M. residents on their inpatient rotations).

35. General Recommended E.M. Training for Residents from Other Specialties  Internal Medicine, Family Practice : –1 month in 1st year, 1 month in 2nd or 3rd year  General or Orthopedic Surgery, Anesthesia, Otolaryngology : –1 month in first year  Obstetrics & Gynecology, Pediatrics : –1 month in 2nd or 3rd year  Radiology, Pathology, Psychiatry, Ophthalmology : –May NOT need an E.M. rotation

36. Considerations for an International Clinical Rotation for the E.M. Residents Resident work time for international rotations is not paid to the Program by Medicare Does meet the goals of the six Core Competencies Best reference list of rotations is on the A.C.E.P. International E.M. Section sub-web site ; E.M.R.A. is also accumulating a new list Shown to be an attractive feature for residencies with applicants

37. Career Options for E.M. Residents Graduating from U.S. Programs  Private practice –Single hospital physician group –Multi-hospital physician group  Academic practice –Mix of clinical work, teaching, research –Focus on research  Administration –E.D. director –Prehospital system director  Additional fellowship training  Locum tenens work Program Directors should be able to prepare their residents for any of these

38. How to Run an E.M. Residency Program : Summary The most important ingredient for a successful residency is an enthusiastic, dedicated, and knowledgeable Program Director assisted by an energetic Program Coordinator. Successful E.M. residency operation depends on monitoring and maintaining high quality in each of the many structural and human components of the residency.