Recently, a group of clinician-educators were discussing the nuances of a new standard, grousing about new experience requirements, pointing out absurd details and gossiping about programs that may close. It was a discussion that is familiar to EMS administrators and managers, many of whom are moving state credentialed ALS providers to National Registry Advanced EMT status.
This was not another National EMS Education Standards implementation work session. These were emergency medicine physicians updating an EMS fellowship program and preparing for the first subspecialty board examination.
The American Board of Emergency Medicine (ABEM) recognized EMS as a subspecialty certification for ABEM diplomats in September 2010. Certification comes from a combination of training, mentorship and practice, culminating with a 200 question examination. The first exam is anticipated for late 2013.
Within the American Board of Medical Specialties there are 24 member boards that represent 145 medical specialties and subspecialties. Emergency Medicine became the 23rd medical specialty in 1979.
The pathway to specialization starts with graduation from medical school, followed by a three-to-four year emergency medicine residency, then a one-to-two year EMS subspecialty fellowship. In Academic Year 2010-2011, ACGME reported 5190 physicians enrolled in 155 Emergency Medicine programs.
When fully formed, an Accreditation Council for Graduate Medical Education (ACGME) approved EMS fellowship will provide the primary pathway to the board exam. The program will cover the core content of the unique EMS body of knowledge with a clinical emphasis.
What an ACGME accredited EMS fellowship will look like
ACGME accredited fellowships establish minimum standards and duties for the institution, fellowship director, faculty and students. The standards provide detailed descriptions of tasks and experiences. They address unique workload issues with graduate physician medical education that paramedics and ems administrators may not know about.
Two EMS faculty members dedicate a minimum of five hours per week of direct teaching time to fellows. Much graduate physician education is done face-to-face during delivery of clinical services. In addition, at least three hours a week are planned educational experiences. These planned experiences include:
- Presentations based on the EMS Fellow curriculum
- Morbidity and mortality conferences
- Journal review
- Administrative seminars
- Research methods
The 25 existing non-accredited EMS fellowship programs are mostly funded from revenue generated when fellows are engaged in clinical practice; such as working in the emergency department. ACGME imposes an 80 hour weekly limit on duty hours.
Why is this important?
For decades, EMS has been an emergency medicine “hobby.” EMS lacked the organizational weight and value that other emergency physicians enjoy when specializing in medical toxicology, hospice/palliative, pediatrics, hyperbaric and sports medicine. In those subspecialties, practitioners received full credit for their endeavors and have a recognized professional development practice and academic pathway.
Now a physician can have a primary professional focus on EMS, with a clear and consistent pathway. There are excellent home-built EMS fellowships, which will raise the bar for some.
This also will improve the academic promotion path at medical schools and universities. Activities related to an accredited fellowship frequently carry more weight for tenure-track faculty.
Finally, this process codifies the breadth, uniqueness and complexity of an EMS fellowship program. The content of the fellowship curriculum is subdivided into four areas:
- Clinical Aspects of Prehospital Medicine
- Medical Oversight of EMS
- Quality Management and Research
- Special Operations
This matches the four volumes issued by the National Association of EMS Physicians (NAEMSP) Emergency Medical Services: Clinical Practice and System Oversight in 2009. These textbooks establish the unique body of EMS knowledge, a key component for recognition as a medical subspecialty.
How does this affect EMS education?
This summer we test-taught an EMT course using a brand new textbook and did our best to comply with the educational standards. After two decades of teaching to a tightly scripted vocational training program, the transition was cumbersome.
The knowledge areas covering “old school” EMT-Ambulance and paramedic topics were no problem, but there were a dozen areas where the textbook met the educational standards that the information lacked focus and clarity.
As the EMS Fellows proceed through their experience, we will probably find them filling in the blanks for the clinical aspects of EMT, Advanced EMT and Paramedic curriculum through research, presentations and content development.
How does this affect ems operations?
Clinically excellent EMS systems feature an active and engaged medical director. EMS Fellowship encourages an active physician medical director, such as this requirement:
“Minimum of 12 months of clinical experience as the primary or consulting physician responsible for providing direct patient evaluation and management in prehospital setting as well as supervision of care provided by all allied health providers in prehospital setting.”
Physician supervision of prehospital care providers repeatedly shows up in the ACGME application.
If you are working in an urban system, please review the statement developed by the 2007 U. S. Metropolitan Municipalities’ Medical Directors. The Eagles statement: “Evidence Based Performance Measures for Emergency Medical Service Systems: A Model for Expanded EMS Benchmarking” was published in the April/June 2008 issue of Prehospital Emergency Care.
They recommend measuring of six clinical activities, abandoning any Advanced Life Support response standard, and focusing on patient outcomes. We will look at how Wake County EMS in North Carolina is measuring the “Number Needed to Treat” in a later column.
Get Educated
EMS Administrators and Managers will be swept along as physicians grow their subspecialty. Here are two suggested readings:
Zink, Brian J, MD (2006) Anyone, Anything, Anytime: A History of Emergency Medicine. Mosby Elsevier, ISBN 1-56053-710-8
Cone, David A. and Brice, Jane H (2010 June) “EMS as a Recognized Subspecialty: Implications for Fellowship Training” presented at the Society for Academic Emergency Medicine annual meeting, Phoenix AZ. Accessed November 05, 2011 from: http://www.naemsp.org/documents/EMSFellowships_SubspecialtyHandhouts.pdf
