EMEU-4012 - Acting Internship in Emergency Medicine

EMEU-4012 - Acting Internship in Emergency Medicine

Elective Title: Acting Internship in Emergency Medicine
Course Number: EMEU-4012
Elective Type: clinical Duration/Weeks: 4 Max Enrollment: 1
Prerequisites: Successful completion of Year 3
Additional Requirements: C-form required.
Responsible Faculty Director: Paul Koscumb, MD Periods Offered: 1-13 including holiday period 8 
Coordinator: Vanessa Phillips Other Faculty: Dietrich Jehle, MD
Location to Report on First Day:
John Sealy Emergency Trauma Room 3.114 (for questions please contact Ms. Vanessa Phillips valphill@utmb.edu)

The AI in Emergency Medicine is designed to provide advanced exposure to medical students to the field of Emergency Medicine. Students will work within the General Competencies and Medical Education Program Objectives outlined by the John Sealy School of Medicine to advance and hone their skills in rapid assessments of the ill or injured pediatric/adult patients and to develop knowledge and skills allowing them to manage commonly presenting adult and pediatric emergencies at an intern level with more limited input from staff physicians.
1. Increase their familiarity and use of common ED procedures and diagnostic tools to include point of care ultrasound. The rotation will also strive to increase comfort in the independent completion of procedures with safe supervision.
2. Use system-based practice aid patients across the clinical and socioeconomic spectrum as well as developing disposition and treatment plans which incorporate the influence social determinants of health to provide optimal care.
3. Further Develop communication and presentation skills to ED faculty and to consultant services.

Develop and introduce students to skills in the six core competencies of ACGME prior to residency specifically in the Emergency Department.
Build on prior experiences and improve rapid assessments of the ill or injured pediatric patient and to develop knowledge and skills allowing them to manage both adult and pediatric emergencies.
1. Patient Care:

Improve on and demonstrate the ability to obtain accurate and relevant medical histories, perform thorough physical exams, and order appropriate diagnostic tests for a variety of patients presenting to the emergency department.
Demonstrate proficiency in the assessment and management of critically ill patients, including but not limited to those with respiratory distress, sepsis, acute coronary syndrome, anaphylaxis, emergent traumatic injuries, and shock.
Demonstrate proficiency in the assessment and management of patients with acute pain and use of a multimodal pain plan to include non-narcotic and narcotic medications and assist with and know indications for procedural sedation.
2. Medical Knowledge:
Demonstrate a thorough understanding of the basic pathophysiology and natural history of common emergency department presentations, including but not limited to adult and pediatric chest pain, shortness of breath, allergic reactions, musculoskeletal injuries, pelvic and pregnancy complaints, abdominal pain, and altered mental status.
Demonstrate familiarity with the indications, contraindications, and potential complications of commonly used emergency department medications and procedures. Pain medications, antiemetics, antibiotics, antiarrhythmics, anti-epileptics, sedatives, and others. Procedures to include but not limited to EKG interpretation, laceration repair, lumbar puncture, peripheral and central venous access, airway management, incision and drainage, and orthopedic reductions and splinting.
Demonstrate proficiency in the interpretation of common laboratory and imaging studies, including EKGs, chest x-rays, and CT scans.
3. Practice-Based Learning and Improvement:
Demonstrate the ability to use evidence-based medicine and clinical resources such as UptoDate to guide clinical decision-making, including the use of clinical guidelines and systematic reviews.
Demonstrate a commitment to continuous learning and improvement, including seeking feedback from attendings and residents, and reflecting on and modifying one's own practice in response to feedback.
4. Interpersonal and Communication Skills:
Demonstrate the ability to communicate effectively with patients, their caregivers, and their families from diverse backgrounds, to incorporate social determinants of health, including the ability to provide clear explanations of diagnoses and treatment plans, and to elicit and effectively address patient and family concerns and questions.
Demonstrate the ability to work effectively with interdisciplinary teams, including nurses, respiratory therapists, social workers/care managers, and consulting specialists.
Demonstrate a commitment to professionalism and ethical behavior, including the ability to maintain confidentiality, act with integrity, and display empathy and compassion towards patients and colleagues.
5. Professionalism:
Demonstrate a commitment to patient safety with observation and completion of patient hand-offs, reviewing and developing best practices in medication safety, and developing a process to obtain informed consent from patients undergoing invasive procedures.
Use the Acknowledge, Introduce, Duration, Explanation, Thank you (AIDET) with patients, caregivers, and parents.
Demonstrate a commitment to cultural humility and sensitivity, including the ability to recognize and address biases and stereotypes in one's own thinking and practice.
6. Systems-Based Practice:
Develop and demonstrate an understanding of the broader healthcare system, including the roles of emergency medicine within that system and the potential impact of policy and regulatory changes on emergency medicine practice.
Develop and demonstrate proficiency in the use of electronic health records and other healthcare technologies to support clinical decision-making and communication.
Demonstrate an understanding of the importance of resource utilization and the need to balance quality of care with cost-effectiveness in emergency medicine practice.

Description of course activities
Students will be providing or supporting emergency care for acutely injured or ill patients in the emergency departments (EDs) at Main Galveston campus. When providing patient care. Under the direct supervision of faculty members, students will assess patients, formulate patient care plans, and implement patient care plans. In addition, they will observe, assist, and/or perform procedures as needed to care for their patients. They will attend approximately 120 hours of clinical shift time in the Emergency Department. They will attend weekly didactics sessions, grand rounds, and other learning seminars/labs as scheduled. Depending on availability and offerings during that month. Didactics and learning opportunities may supplement clinical shift time. Schedule will vary as it is 12 12 hour shifts over 4 weeks with an average of 5 each day and night shift.

Type of students who would benefit from the course
4th year medical students interested in a career in Emergency Medicine

    Weekly Schedule
          Estimated Course Activities (Start-Time/Finish-Time):
Day of Week   AM   PM
Tuesday 7:00 7:00
Wednesday 7:00 7:00
Friday 7:00 7:00

 Average number of patients seen per week: 20
 Call Schedule: No

Research / Other Course Activities
(estimated schedule)
Activity Hours per Week
Faculty Contact-Time
Self-Directed Study

Method of Student Evaluation
1.  Clinical Observation
  A. Where are students observed on this elective?
    Inpatient Service   Ambulatory   Surgery   Standardized patients
Patients simulators   Other
  B. Frequency - How often are students observed clinically?
    Will be observed clinically by the attending at every daily clinical shift.
  C. Format - What method(s) are used to document the student's clinical performance?
    Daily oral feedback   End of period oral feedback   Written feedback

2.  Oral Presentation
  A. Audience - To whom does the student present?
  B. Frequency / Duration of Presentation(s)?
  C. Format - What guidelines are set for the student's presentation?
    SOAP presentation format. Also, each student will present a patient case writeup and learning point relevant to Emergency Medicine of their choosing by the midpoint of the month (and faculty approval)
  D. Assessment - Who assesses the student's presentation performance?
    Self-assessment   Peer assessment   Faculty assessment
  E. Method of content selection
    Current cases  Student-selected topic   Assigned topic

3.  Written Assignment (H&P's, notes, papers, abstracts, etc.)
  A. Frequency of written assignment(s)?
    Unit admissions, progress and note forms / PowerPoint, handouts or chalkboard description may be used for the case presentation
  B. Format - What guidelines are set for the student's written work?
    Unit admissions, progress and note forms / PowerPoint, handouts or chalkboard description may be used for the case presentation
  C. Length of written assignment(s)?
    Abstract   Annotated bibliography   1 - 2 page paper   3+ page paper
  D. Are recent references required?   No    If yes, how are they selected?
  E. Method of content selection - e.g. student-selected, relate to cases, etc.?
    Current cases, and student-selected
  F. Audience - Who assesses the student's written performance?
    Peer Assessment     Faculty Assessment     Other

4.  Examination
    Oral   Written multiple choice   Written essay / short answer   OSCE

5.  Extra Course Activities
  What expectations do you have for the student to demonstrate participation in the elective (e.g. small group activities, seminars, thoughtful questions, providing resources, journal club, resident lecture attendance)?
    Attendance during weekly student didactics sessions

6.  Additional Costs
  Please list any additional costs and/or purchases (books, materials, movies to watch, etc.) that are required for this course. Include an estimated total cost. If there are no additional costs, please enter "None".

7.  Other Modes of Evaluation
  Please explain below.

8.  If this course is an Acting Internship, please complete the following:
  A. Objectives for the AI should relate directly to the Entrustable Professional Activities (EPAs). Each AI should describe how the four key Year-4 EPAs that our school has identified as being Year-4 skills are assessed. The Year-4 objectives are:
1. Entering and discussing orders/prescriptions.
2. Give or receive patient handover to transition care responsibility.
3. Recognizing a patient requiring urgent or emergent care and initiating management.
4. Obtaining informed consent for tests and procedures.
Specify how the student will be given formative feedback on their clinical skills.
    They will enter orders and medications in the EMR, review these with faculty, and develop clinical plans together. They will conduct handoffs of their patients to incoming staff/residents to improve skills in both receiving and performing handoffs in a safe observed environment.
Recognizing a patient requiring urgent/emergent care is a core tenet of EM, so they will have numerous opportunities to perform this. They will participate in and learn how to obtain informed consent for any procedures they are part of or completing. Formative feedback will be given on all these observed interactions and opportunities for improvement will be identified. Feedback will come from faculty and residents.

Year-4 students should demonstrate mastery of EPAs they developed in the clerkship year, including recommending and interpreting common diagnostic and screening tests, and performing general procedures of a physician. They should be able to demonstrate masterfully and independently skills they mastered in Years 2-3, including efficiently performing comprehensive admission-notes and succinct daily progress notes and perform accurate, concise, and hypothesis-driven clinical presentations, form clinical questions and retrieve evidence to advance patient care. They should be able to demonstrate basic understanding of and beginning mastery of collaborate as a member of the interprofessional team and identify system failures and contribute to a culture of safety improvement.

List advanced clinical skills that a student will be assured an opportunity to practice.
    ECG interpretation. Point of Care Ultrasound. X ray interpretation, ABG/VBG interpretation, fracture reduction/splinting. Advanced IV and central line access, non-invasive and invasive airway management.

How specifically will this AI build on developing skills from the clerkship year to prepare students for internship?
    During the selective we focused on managing the emergent and acute care of 1 patient, and specifically now we wish to broaden their exposure and responsibilities to the care of multiple patients, consulting treating physicians/services, and performing procedures themselves. We will also work on medication dosing, ordering, and discussion of side effects and potential harms from medication administration.

What opportunities will typically be available to all students who take this AI (procedures, required presentations, etc.)? What opportunities may be available based on patient load/presentation or student initiative (ie. Writing a case report)?
    They will have opportunities to review cases with faculty on shift. The AI is expected to gather and interpret patient information, develop a management plan, and to implement basic steps in the plan, similar to an intern. Should they evaluate a particularly notable case, then they may have the opportunity to write a case report with the faculty that saw the patient.

An AI should have expectation of a minimum of 32 hours per week of clinical responsibilities. Duty hours should be capped at ACGME limits for an intern, thus up to 24 hours followed by 4 hours of activities related to patient safety, education, and handoff. Students cannot work more than 80 hours per week averaged over 4 weeks. They can only have 1 day off in a 7-day work week with 8 hours off between shifts.

Clinical responsibilities will vary depending on specialty, but how is the student functioning with work commensurate to a PGY1 with an appropriate level of training?
    They will work at an equal level to that of our interns. Their shift load will be similar, and the focus will be on increasing efficiencies and follow-up/ownership of their patients so that they improve much more and are able to assess and care for 3-4 patients at a time.

How is the student demonstrating drawing clinical conclusions and/or developing a management plan and documentation as an intern would do?
    We will allow them much more discretion in creating the diagnostic plan and further evaluations. They will place orders independently that we will verify and co-sign, and that will allow us to assess how they have integrated clinical information and generated their differential diagnosis and lead to fruitful conversations during presentations. They will have them chart a patient’s complete clinical experience which will allow for on-shift immediate feedback as well.

How and by whom will midpoint feedback be provided to the student? How will you remediate deficiencies identified at midpoint?
    Feedback will be given after the second week if requested. The student will evaluate themselves and then the course director will assess that for formative feedback. They will make a list together of midpoint improvements we will seek to see, and that will be addressed in the final feedback

Acting Internship students often seek letters of recommendation following their experience. How many different Faculty will work directly with the student and have knowledge of the student's abilities to detail in a written evaluation? Describe the degree of supervision and interaction with faculty vs. residents or other providers and how feedback will be obtained if more direct work is with residents or other providers.
    Students will be be provided if requested a standardized letter of evaluation (SLOE). This will draw on entire faculty group experiences with that student, and be written jointly by the core EM faculty (~10). Resident feedback will be solicited, but it will primarily be from experiences with core faculty. Evaluations/letters will be a collaborative effort discussed during monthly core faculty meetings.