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COMPETENCY
Hayden, Panacek • PROCEDURAL COMPETENCY IN EM
EDUCATIONAL ADVANCES Procedural Competency in Emergency Medicine: The Current Range of Resident Experience STEPHEN R. HAYDEN, MD, EDWARD A. PANACEK, MD
Abstract. Objectives: To evaluate the recorded range of procedures tracked by emergency medicine (EM) programs, and to determine whether differences in procedural experience occur in various types of residency or hospital settings. Methods: The program directors of 112 approved EM programs were asked to send actual procedure logs. The requested information included the average total number of a given procedure per graduating resident, for all procedures that were tracked. Data were categorized by program format, hospital type, and ED volume. To assess the global procedural experience among programs, a set of 22 ‘‘index procedures’’ were identified; all procedures the EM residency review committee (RRC-EM) required to be tracked were included in this set. The means per graduating resident for each index procedure were added together to generate a ‘‘mean index procedure sum’’ (MIPS) per graduating resident for each residency program. These MIPSs for a residency were then compared by program format, hospital type, and ED volume. A similar analysis was performed for all resuscitations, and a ‘‘mean index resuscitation sum’’ (MIRS) per graduating resident was generated. Results: An overall response rate of 82% was achieved; a number of programs had not graduated a residency class and were not included. Sixtyfive of 85 eligible programs (76%) provided procedural data. The average number of a given procedure per
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OCUMENTING proficiency in procedural skills is becoming increasingly important for all physician training programs, including emergency medicine (EM). The core content in EM1 contains 81 distinct procedures. Applicants to the American Board of Emergency Medicine (ABEM) may be tested on each of these, and it is expected From the Department of Emergency Medicine, University of California San Diego Medical Center, San Diego, CA, and the Division of Emergency Medicine, University of California Davis Medical Center, Davis, CA (SRH, EAP). Received January 1, 1999; revision received January 23, 1999; accepted February 16, 1999. Presented at the SAEM annual meeting, Denver, CO, May 1997. Address for correspondence and reprints: Stephen R. Hayden, MD, Department of Emergency Medicine, UCSD Medical Center, 200 West Arbor Drive, San Diego, CA 92103-8819. Fax: 619-543-3115; e-mail:
[email protected]
graduating resident (95% CI in parentheses) for selected procedures is as follows: oral intubation 65 (46 to 85), intubation unspecified 75 (62 to 87), nasal intubation 6 (4 to 9), cricothyroidotomy 2 (1 to 2), subclavian catheter 23 (16 to 30), chest tubes 17 (14 to 20), intraosseous line 2 (1 to 3), thoracotomy 3 (2 to 5), and vaginal deliveries 17 (13 to 21). The only statistically significant differences in subgroup comparisons were in diagnostic peritoneal lavage, trauma resuscitations, and pediatric medical resuscitations when compared by postgraduate year format, and intubation—unspecified and cricothyroidotomy when compared by hospital type. There was no statistically significant difference when MIPSs were compared by format, hospital type, or ED volume. Conclusions: To the authors’ knowledge, this is the first study of the range of EM resident procedure experience across the spectrum of EM residency types and settings. Overall, there are few statistically significant differences in procedure experience among different program formats. Similar experiences are recorded in a variety of different hospital types or ED volumes. However, some programs report very limited EM resident experience with selected critical procedures. There is a large variation in the types and numbers of procedures recorded by EM programs. Key words: emergency medicine; procedure; resident physician. ACADEMIC EMERGENCY MEDICINE 1999; 6:728–735
that EM training programs should provide residents experience or education in all of them. The Residency Review Committee for Emergency Medicine (RRC-EM) identifies 16 emergency procedures and four types of resuscitation that EM residencies (EMRs) must track in the form of a procedure log.2 Although the RRC-EM requires procedure tracking, there are currently no published competency criteria, or minimum number of procedures required for board certification in EM. It is also not clear what range of procedure experience occurs in EM training programs. Emergency medicine is not alone in the lack of specific criteria for establishing procedural competency. The American Boards of Anesthesia, Pediatrics, and Family Medicine do not currently require formal documentation of procedural expe-
ACADEMIC EMERGENCY MEDICINE • July 1999, Volume 6, Number 7
rience. The American Board of Surgery requires submission from applicants for specialty certification of 500 operative cases, 150 of which must have been done in the year prior. There is no set number of individual cases required but the board publishes a list of procedures that qualify. In 1991, the American Board of Internal Medicine approved a policy specifying seven procedures that candidates to the board must master. These include abdominal paracentesis, arterial puncture, joint aspiration, central venous access, lumbar puncture, thoracentesis, and nasogastric tube placement.3 New York State requires hospitals to credential all houseofficers in a specified set of procedures.4 Anecdotally, hospital credentials committees are increasingly asking emergency physicians (EPs) for documentation of procedural experience, including numbers of specific procedures, as part of the application for hospital privileges. Our objective was to evaluate the recorded range of procedures that are being tracked by EM programs. Before any statements are made regarding recommended EM resident procedural experience, a description of what currently exists is necessary. Additionally, we sought to determine whether significant differences in procedural experience occur in various types of residency or hospital settings.
METHODS Study Design. This was a descriptive study of procedures performed by EM residents from approved EM residency programs. Comparisons were made of total procedures done as reported in procedural logs, as well as procedures by program format, hospital type, and ED volume. This study was considered exempt from institutional review board approval. This project was discussed with the SAEM Residency Committee and approved by the Council of Emergency Medicine Residency Directors (CORD). Study Population and Protocol. Letters were initially sent to the program directors of the 112 EM programs approved as of January 1997. Program directors were asked to provide actual procedure logs. If this detailed information was not available, we then asked for a copy of the procedure summary page from the Program Information Forms (PIFs) of the program’s most recent RRC review. The average total number of a given procedure per graduating resident was the main outcome measure, and this was tabulated for all procedures that were tracked by a given program. We also asked whether the information represented actual recorded numbers or a best-guess estimate. To increase the response rate, three rounds of let-
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ters requesting information were sent to program directors on CORD letterhead, and multiple requests were sent via the CORD e-mail list server over the next several months. All information was handled in a confidential manner. As each package was received, it was opened by a support staff member and given a study number. Data were entered into the database according to this number. Subgroup comparisons were made by program format (PG-123, PG-1234, PG-234), hospital type (university, community, county/public), and ED volume of the primary training site (
