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
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Effects of External Forces on Emergency Medicine Residency Training in the US
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.
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Effects of External Forces on Emergency Medicine Residency Training in the US
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.
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Effects of External Forces on Emergency Medicine Residency Training in the US
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.
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Effects of External Forces on Emergency Medicine Residency Training in the US
In addition, they may not be trained/allowed to perform functions such as answering the telemetry radio
for the EMS system or providing nursing functions to a level 1 trauma patient, thus placing an undue
burden on other nurses or the house staff for many aspects of routine emergency care.
Further compounding the immediate problem of supply and demand is the reported effect of the nursing
shortage on nurse burnout. This dissatisfaction leads to higher nurse turnover; some studies report
approximately 25 percent of first year nurses. The result is a significant percentage of nurses that are illequipped for or are new to EDs. The number of nurses with inadequate ED experience may shift
departmental duties to the fixed supply of staff on which the ED can rely --- the resident physicians.
Resident experience with certain nursing duties can be beneficial in both understanding the medical care
and challenging role emergency nurses play. Depending on residents to perform these duties too much,
however, is concerning in that it may dilute their overall training. Attention should be given to increasing
the number of emergency nurses and advocating for programs and programs that increase nursing
retention. Another viable solution that may decrease some of the nursing workload in a cost-effective
manner is increasing the number of paramedics and ancillary staff.
Medical Liability Environment
In 2003, ACEP’s Academic Affairs Committee conducted a survey of senior emergency medicine
residents and found that the majority of residents about to graduate had concerns about accepting a job in
certain states because of perceived or real medical malpractice liability issues. The most problematic state
at that time was Pennsylvania with Illinois and Washington also mentioned as concerning states in which
to practice; twenty percent of residents stated that they would not even consider practicing in a particular
state due to malpractice concerns.
Further, residents felt that the threat of a malpractice claim, i.e. an unfavorable practice climate, was as
important as the expense of malpractice insurance, in determining concerns about whether to locate in a
particular state.
It was also clear that states that had addressed the malpractice liability crisis with more favorable
legislative and administrative relief, e.g. the introduction of malpractice caps, were viewed more
positively. Senior residents at the time of the survey viewed Florida and Nevada as having implemented
changes along these lines that made them more attractive practice venues
It has been suggested by several groups, including the AMA, that a more comprehensive national
approach to the liability crisis be undertaken. This is particularly important since several states who have
addressed these issues by implementing legislation have been overturned by the Supreme Court of that
state. One notable example is Illinois, where this has happened twice in the last two decades.
Interestingly, the malpractice premiums for an emergency physician in Cook County (Chicago area) are
three times higher than for an emergency physician who practices in the adjacent county of north western
Indiana, where malpractice caps and a malpractice review board are in place on a state-wide basis.
An adverse malpractice environment also increases the cost of medical care due to over ordering of tests.
These additional tests contribute to ED crowding by increasing patient length of stay.
It also leads to a change in the quality of instruction of EM residents who are learning in such an
environment. This is a consequence both of fewer patients seen per hour by the resident in an over
crowded setting and the effect witnessed by the resident of “defensive” test ordering behavior of attending
physicians who have changed their practice to adopt a more risk averse approach to clinical medicine.
This risk averse approach occurs because of malpractice events within their group (or personally) or a
concern for national data bank reporting requirements.
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Effects of External Forces on Emergency Medicine Residency Training in the US
Regulatory Agency Requirements
Because each state department of health (DOH) is different, emergency physicians and EM residents need
to familiarize themselves with the ED and hospital rules and regulations of the specific DOH in the state
where they practice and train.
Such rules may have a profound effect on the EM resident clinical and educational experience. There is
no better example of this than the varied state DOH regulations regarding the use of hospital and ED
hallway beds. The New York DOH allows the use of both ED and hospital inpatient hallways for
admitted patients boarded in the ED. This has resulted in the development and publication of a webbased “full capacity protocol” that has now been universally adopted as a high impact solution for ED
crowding.
Conversely, Pennsylvania’s DOH has forbidden hospitals to use their inpatient hallways for ED admitted
patient boarders unless a hospital- wide disaster has been declared or a flu epidemic has ensued. Taking
this one step further, the Pennsylvania DOH has recently begun issuing citations to hospitals for treating
ED patients in ED hallways. In response, the Chief Executive Officer (CEO) of a busy Chicago hospital
recently instructed his ED medical director not to place any ED patients in ED hallways for evaluation
and treatment, completely backing up hospital and ED patient flow. State DOHs averse to adhering to or
proposing rules and regulations to address solutions to ED crowding, such as the use of alternative
hospital inpatient locations for placement of ED boarders, will continue to negatively impact EM resident
education.
The Joint Commission (TJC) accredits and certifies health care organizations and programs throughout
the country. The organization sets standards that must be followed, and these requirements greatly
influence the process of health care delivery in many settings, including EDs. As part of its 2005 Hospital
National Patient Safety Goals, TJC required that hospitals “accurately and completely reconcile
medications across the continuum of care.” To meet this requirement, service providers need to obtain a
complete list of patients’ medications on admission to the organization. They also must provide a
complete, updated list of patients’ medications upon referral or transfer of patients within or outside the
organization. In 2007, this standard was further expanded to require that a complete list of medications be
provided to patients upon discharge form the facility.
Meeting these standards can be challenging in the unique setting of the ED where patients may not be
able to provide reliable information, patients with serious life threatening emergencies arrive unscheduled
and often without advanced notice, emergency physicians are managing many critically ill patients
simultaneously, and ED crowding has sapped the already scarce resources in many communities.
While some health care systems have responded to these new requirements by providing additional
resources to the ED, such as dedicated pharmacists to assist with medication reconciliation, this is far
from universal. As a result, many EDs must rely upon physicians to perform this task, which may
negatively affect the educational experience of residents in the ED. Medication reconciliation is a timeintensive process that detracts from the ability of EM faculty to supervise and teach residents and medical
students at the bedside.
Since 2002, hand washing has been on the radar screen of the Centers for Disease Control and Prevention
(CDC) when it published its “Guidelines for Hand Hygiene in Health-Care Settings.” There is no question
that hand hygiene reduces hospital-acquired infections and is a major patient care and safety initiative.
Proper hand hygiene takes time with the gold standard requiring a minimum of 30 seconds of activity. In
addition, most institutions now advocate for hand hygiene practices both before and after each patient
contact. Very few hospitals, however, have moved to make hand hygiene practices easy for staff. Sinks
and dispensers for either alcohol-based hand-rubs or antimicrobial soaps are often inconveniently placed
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Effects of External Forces on Emergency Medicine Residency Training in the US
or inaccessible. Satisfying this important requirement without appropriately located resources takes away
time from important resident teaching.
Similarly, no one would argue in doing away with dangerous abbreviations in medical documentation. In
2007, TJC’s National Patient Safety Goal 2 asked for improved effectiveness of communication among
caregivers. Goal 2B specifically asked hospitals to standardize a list of abbreviations, acronyms, symbols
and dose designations that were not to be used throughout the organization. However, many teaching
hospitals have failed to communicate this mandate effectively to GME committees, program directors or
residents and have been slow to establish transparent and easy to use systems to assist residents in
complying with and monitoring these new initiatives.
Despite the good intentions of TJC, the CDC and other governmental agencies, new requirements such as
medication reconciliation and avoidance of dangerous abbreviations in medical documentation, and added
requirements to existing practice guidelines such as hand washing, may negatively impact the educational
mission of teaching hospitals unless implementation of such mandates is well communicated to residents
and program directors, actively engages them in processes to make implementation more effective and
efficient, is afforded the proper time and training, and is accompanied by additional resources.
Impact of More Complex Work-ups and Imaging in the ED
The complexity of ED work-ups has increased with the evolution of advanced technology. It has become
standard practice for the vast majority of emergency patients to undergo computed tomography (CT) of
virtually every body part addressed in the chief complaint, particularly the head, chest and/or abdominal
CT for all patients evaluated for and especially if admitted for the respective body area complaint. This
has added 2-4 hours to the evaluation of many of our patients.
To add to the complexity, we have now entered the era of magnetic resonance imaging (MRI) for
evaluation of patients for admission post-CT scanning; for example, acute stroke patients. In addition,
patients with acute spinal cord related neurological symptoms now receive MRI in the ED as part of their
evaluation. While these are very helpful studies they are also time consuming; ordering MRIs is a
response to both patient and consultant expectations of the capability of the ED service to provide such
studies on an emergent basis- but it adds much time to the ED stay and creates a larger back log of
patients who are not promptly leaving the ED. This diminishes ED capacity, thus directly impacting on
the education of EM residents as discussed above.
Finally, much of the detailed traditional inpatient workup is being completed in the ED, e.g. CT scanning
of fractures, before patients are transported to the orthopedic service, often out of consultants’ concerns
that the patients will not get the scans in a timely manner.
In addition, outpatient workups are now commonly completed in the ED because the health care system is
less able to provide many diagnostic studies in a timely manner on the outpatient basis, thus burdening an
already overwhelmed system. An example is an elective MRI of disc disease being scheduled in the ED
during that initial ED visit, rather than as an outpatient, to help expedite patient care and follow-up.
Impact of a Lack of Inpatient Isolation Beds
During the same time that our nation’s population is both expanding and aging, thus requiring an
expanded health care system, especially the need for inpatient beds, the number of available inpatient
beds has decreased. In addition to the number of inpatient beds is the specific need for isolation beds,
particularly with the increase in Methicillin-resistant Staphylococcus aureus (MRSA), vancomycinresistant enterococci (VRE), and other infections requiring isolation. ED patients often must stay in the
ED for long periods of time until a contact isolation room becomes available, further diminishing our ED
capacity to take care of new patients, thus depriving our residents of new patient contact and care.
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Effects of External Forces on Emergency Medicine Residency Training in the US
Resident Duty Hours
In 2003, the Accreditation Council for Graduate Medical Education (ACGME) implemented resident duty
hour restrictions to address increasing concern about medical errors and resident wellness. Many
clinician-educators hoped that resident duty hour restrictions would reduce fatigue, thereby leading to a
higher yield educational experience with added time for self-directed learning and pursuit of individual
academic interests. However, others worried that duty hour restrictions would lead to insufficient clinical
contact hours and educational experiences needed to create high quality clinicians.
It has been five years since duty hours have been implemented and no research investigating the effects of
duty hour restriction on EM residency education has been published. However, studies from other
disciplines, in addition to multi-specialty studies, have examined resident and faculty opinions regarding
changes in resident education pre- and post-duty hour restrictions. These results give insight to duty hour
restriction’s effect on the off-service aspect of EM training, the component most affected by duty hour
restrictions.
The largest studies of resident opinion regarding changes in residency education post-duty hour
restrictions cite a decline in teaching, mentoring, and direct patient care activities – however, the residents
did not feel that their overall training was significantly better or worse than that training pre-restriction.
In a multi-center survey of two hundred internal medicine and general surgery residents from six
residency programs in five geographically distributed academic medical centers, Myers et al. reported that
residents in training both before and after duty hour restrictions expressed concerns about decreased
opportunities for bedside learning, procedures, and faculty mentoring since the implementation of duty
hour restrictions. Of note, internal medicine residents felt that the value of the overall educational
experience had declined, while surgical residents felt it remained the same. No group of residents reported
an improved educational experience after duty hour restrictions were imposed. All groups observed that
duty hour restrictions led to a shift-work mentality among trainees. There was no consensus amongst the
residents that graduates would be less well trained post-duty hour restriction.
A similar survey of 1,770 residents in seventy-six residency programs conducted by Jagsi et al. in two
Boston area teaching hospitals revealed that residents in thirteen residency programs who experienced a
substantial decrease in duty hours when restrictions were implemented responded more positively to the
new paradigm than did their colleagues. These residents noted that fatigue was now considerably less
likely to negatively impact their ability to learn. In addition, they noted that direct patient-care hours
significantly decreased, while no change was observed in the one-third of time spent performing ancillary
work (i.e. "scut work").
With specific regard to educational quality and adequacy, residents in reduced workload programs
observed two positive differences -- increased quality of instruction in outpatient settings and increased
opportunity to perform research. However, these changes were accompanied by a concerning decrease in
quality of faculty teaching and no improvement in quantity of didactics, informal teaching, or selfdirected learning. Similar to the Myer’s study, this group of residents agreed that there was no change in
the clinical spectrum of patients experienced or change in the overall satisfaction with education they
received.
Finally, Vidyarthi et al., surveyed 125 internal medicine residents at three California clinical training sites
who agreed with those in the Jagsi study, reporting that time spent in administrative activities did not
change after duty-hour restrictions. Notably, 68 percent opined that decreased duty hours had no impact
or a negative impact on their education. At these training sites, duty-hour reduction did not improve
educational satisfaction, leading the authors to conclude that educational satisfaction may be more a
function of workload than hours worked.
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Effects of External Forces on Emergency Medicine Residency Training in the US
Faculty and program directors have more negative opinions than do residents with regard to duty hour
restriction’s effect on resident education. In a large multi-specialty study, Dola et al. surveyed residents
and faculty at a large university-based teaching hospital, the two espoused divergent views regarding
impact on resident education. Residents reported a positive impact on resident reading time and clinical
decision making; they declared the rules to be generally beneficial to resident education. In contrast, only
a minority of faculty members perceived that duty hour rules improved resident education.
Negative views held by the faculty also characterize several studies comparing faculty and resident
opinions within single disciplines. Cull et al. surveyed 161 pediatric program directors and 500 pediatric
residents in training programs before and after implementation of duty hour restrictions. Program
directors perceived a worsening in the quality of resident education which was also detected to a lesser
degree by the residents.
Residents and faculty in otolaryngology surveyed by Brunworth et al. did not detect improvements in
self-study, research, or board exam performance. Paralleling the opinions of the pediatric faculty and
residents, 69 percent of otolaryngology faculty reported a negative effect on resident education, whereas
only 31 percent of residents felt their education had been negatively affected.
Cohen et al. found that neurosurgery residents and faculty also agreed that duty hour restrictions had an
overall negative impact on their training program.
Finally, in a survey of family medicine program directors done by Peterson et al., only 4 percent felt the
residents fared better overall under the duty hour restrictions, expressing significant concerns about
decreased formal education opportunities and the creation of expectations are likely to be inconsistent
with the realities of practice.
In addition to the perceived decrease in patient contact and teaching, there will likely be longer term
consequences of the ACGME imposed duty hour restrictions that have the potential to further negatively
affect residency education.
In a survey of 248 faculty at a single teaching institution, 56 percent feel they presently have less time for
teaching post-duty hour restriction. Furthermore, 43 percent were less satisfied with their jobs after
implementation of resident duty hour restrictions, suggesting that it will be difficult to maintain and
recruit teaching faculty. This last conclusion bodes poorly for future affects of duty hours restrictions on
the quality of residency education in the US.
Diversity and Socioeconomic Factors
The challenges posed by diversity issues will only become more pronounced in coming years. It is
projected that there will be at least 69 million Americans who speak a language other than English at
home and 28.4 million with limited English proficiency.
Multiple studies have demonstrated decreased quality of care and increased costs associated with the lack
of appropriate translation services. These problems are exaggerated in the ED where time and acuity
pressures are extreme. EM training programs must ensure adequate translation services that are available
and convenient for ED use.
Another issue related to the influx of immigrants is the employment of traditional medicines and
practices. Recognition of diverse health practices (coining, acupuncture, yoga, Ayurvedic medicines, etc)
as appropriate complements to Western medicine improves physician-patient relationship. Nevertheless,
traditional health practices are not necessarily benign. For example, traditional medicines can contain
toxic ingredients (lead, cyanide, etc.) and a full investigation of all medicines the patient is taking is
essential.
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Effects of External Forces on Emergency Medicine Residency Training in the US
Finally, vulnerable populations such as prisoners, children, minorities, and patients with limited English
proficiency generate intense scrutiny with regards to any research involving such groups. This can
prolong the institutional review board (IRB) process and necessitate devotion of increased resources to
such groups in order to satisfy informed consent requirements. While these protections are in place for
valid reasons, they may discourage investigators from targeting or including such populations because of
logistics.
Socioeconomic issues are also playing a prominent role in EM training primarily with regard to uninsured
populations. Teaching institutions often serve as safety net hospitals for their respective metropolitan
areas. Consequently, given the declining number of EDs and inpatient hospital beds and increased
numbers of uninsured patients, teaching institutions are often overwhelmed with patients – both fully
insured, underinsured, and uninsured.
Moreover, fewer surgical subspecialists are taking emergency call due to lifestyle, liability, and
reimbursement concerns. This forces patients to be transferred to hospitals with appropriate coverage,
more often than not, a teaching institution, and almost always, an ED that serves as a training site for EM
residents. Though this increases the variety and complexity of patient cases that an EM resident may see,
it is an additional patient entering an already crowded working environment. These issues have
contributed to overcrowding in our larger general hospital EDs throughout our nation and our teaching
institutions’ EDs in particular.
In addition to overcrowding, reimbursement concerns continue to threaten the financial solvency of
clinical training sites, particularly given the vagaries of federal funding for GME.
Finally, recent research has raised concern over the care of the uninsured. Multiple studies have
demonstrated decreased intensive care unit (ICU) admissions, hospital days, and levels of care for
uninsured patients when compared with insured patients who have equivalent diagnoses. We must strive
to be consistent in the care of our patients. Unfortunately, the number of under and uninsured is likely to
only increased barring a paradigm shift in the US health care system. Thus, teaching institutions must find
creative and sustainable solutions when faced with the problem of increased numbers of patients, and
increased numbers of the uninsured.
REFERENCES
Institutional Crowding
Heins, e. a. (2005). "A Research Agenda for Studying the Effect of Emergency Department Crowding on Clinical
Education." Acad EM 12(6): 529-532.
States, C. o. t. F. o. E. C. i. t. U. (2007). Hospital-Based Emergency Care: At the Breaking Point, National Academic
Press
Crowding and Disaster Preparedness
Kaji, A., Waeckerle, JF (2003). "Disaster Medicine and the Emergency Medicine Resident." Ann Emerg Med 41(6):
865-870.
Kellermann, A. (2006). "Crisis in the Emergency Department." N Engl J Med 355: 1300.
Moye, e. a. (2007). "Bioterrorism Training in U.S. Emergency Medicine Residencies: Has It Changed Since 9/11? ."
Acad Emerg Med 14(3): 221-227.
States, C. o. t. F. o. E. C. i. t. U. (2007). Hospital-Based Emergency Care: At the Breaking Point, National
Academies Press
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Effects of External Forces on Emergency Medicine Residency Training in the US
Medical School Indebtedness
"Medical Education Debt/Loan Repayment-Forgiveness." from
http://www.acep.org/practres.aspx?LinkIdentifier=id&id=22472&fid=1710&Mo=No&acepTitle=Medical%20Educ
ation%20Debt/Loan%20Repayment-Forgiveness.
Hospital Patient Flow and Operations
"Full Capacity Protocol." from www.hospitalovercrowding.com
ED Nursing Shortage
"AACN Fact Sheet." from http://www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm.
Regulatory Agency Requirements
"The Joint Commission Website; 2007 Ambulatory Care/Office-Based Surgery National Patient Safety Goals."
(2002). Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention.
Resident Duty Hours
Brunworth, J., Sindwani, R (2006). "Impact of duty hour restrictions on otolaryngology training: divergent resident
and faculty perspectives." Laryngoscope 116: 1127-1130.
Cohen-Gadol, A., Piepgras, DG, Krishnamurthy, S, Fessler, RD (2005). "Resident duty hours reform: results of a
national survey of the program directors and residents in
neurosurgery training programs." Neurosurgery 56: 398-403.
Cull, W., Mulvey, MA, Jewett, EA, et al (2006). "Pediatric residency duty hours before and after limitations."
Pediatrics 118(6): e1805-e1811.
Dola, C., Nelson, L, Lauterbach, J, et al (2006). "Eighty hour work reform: faculty and resident perceptions." Am J
Obstet Gynecol 195: 1450-1456.
Jagsi, R., Shapiro, J, Weissman, JS, Dorer, DJ, Weinstein, DF (2006). "educational impact of ACGME limits on
resident and fellow duty hours: a pre-post survey study." Acad Med 2006 81(1): 1059-1068.
Myers, J., Bellini, LM, Morris, JB, et al (2006). "Internal medicine and general surgery residents' attitudes about the
ACGME duty hours regulations: a multicenter study." Acad Med 81(1): 1052-1058.
Peterson, L., Johnson, H, Pugno, PA, Bazemore, A, Phillips, RL (2006). "Training on the clock: family medicine
residency directors' responses to resident duty hours reform." Acad Med 81(1): 1032-1037.
Vanderveen, K., et al (2007). "Effects of resident duty-hours restrictions on surgical and nonsurgical teaching
faculty." Arch Surg 142(8): 759-64.
Vidyarthi, A., et al (2006). "Impact of reduced duty hours on residents' educational satisfaction at the University of
California, San Francisco." Acad Med 81(1): 76-81.
Diversity and Socioeconomic Factors
Carrasquillo, O., Orav, EJ, Brennan, TA, et al (1999). "Impact of Language Barriers on Patient Satisfaction in an
Emergency Department." J Gen Intern Med 14(2): 82-87.
Danis, M., Linde-Zwirble, WT, Astor, A, et al (2006). "How Does Lack of Insurance Affect Use of Intensive Care?
A Population-Based Study." Crit Care Med 34(8): 2043-2048.
Medicine, I. o. (2006). "The Future of Emergency Care in the United States Health System." Annals of Emerg. Med
48(2): 115-120.
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Effects of External Forces on Emergency Medicine Residency Training in the US
P, J. (2001). "The Impact of Health Insurance Status on Emergency Room Services." J Health Soc Policy 14(1): 6174.
Quest, T., Franks, NM (2006). "Vulnerable Populations: Cultural and Spiritual Direction." Emerg Med Clin N Am
24: 687-702.
Rhodes, K., Pollack, DA (2006). "Future of Emergency Medicine Public Health Researc." Emerg Med Clin N Am
24: 1053-1073.
Developed by ACEP’s Academic Affairs Committee
September 2008
David S. Howes, MD, Subcommittee Chair
Felix K. Ankel, MD, FACEP
Maj. J. David Barry, MD, FACEP
Ashley E.Booth, MD, FACEP
Jennifer Casaletto, MD, FACEP
Theodore A. Christopher, MD, FACEP
Brian J. DelliGatti, MD
Benjamin W. Hatten, MD
Kristin E. Harkin, MD, FACEP
Laura Oh, MD
Philip H. Shayne, MD, FACEP
Michael D. Smith, MD
L. Albert Villarin, MD, FACEP
Peter E. Sokolove, MD, FACEP, Chair
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