What Makes a Good Emergency Doc?

Published on September 30, 2013
My ED is staffed by physicians of various nationalities and training backgrounds, raising the question: “How important is standardized emergency training?”

Living and working in the Middle East with a large number of doctors from very different backgrounds has made me think about what makes a good emergency doctor.

In my department, I have doctors with vastly different training, all of whom have specialist training in emergency medicine. The training programs vary in length, intensity, exposure to clinical conditions and procedures, cultural grounding and supervision. Some of the doctors come from countries with well-established emergency systems while others trained in systems where emergency care is haphazard and poorly developed. There are doctors with only a few years of experience post graduation from medical school and other doctors who are literally “battle-hardened” from managing war injuries and fighting repressive regimes. As the chief of service, I’ve wondered if any particular group of doctors obviously outperforms the others.

The International Federation for Emergency Medicine has done a lot of work over the last few years establishing consensus on both undergraduate and postgraduate training programs. These are now available on the IFEM website. The core curriculum content is very similar between jurisdictions. Two further documents will be available soon – one on assessment and another on continuing professional development, post specialist training. It is clear from these papers that there is wide variability around the world with most residency programs being between 3-7 years post graduation from medical school. Standard rotations through critical care, paediatrics and so forth are usually mandated. The shorter training programs – such as those in the USA – have now realized that many aspects of an emergency physician’s role need further training. So fellowships have been introduced in many subspecialist areas such as critical care, administration, research, EMS etc.

During training, both formative in-service evaluations and summative examinations are undertaken. Log books for skills and procedures, courses such as ATLS, ACLS are also common. Importantly, there is little benchmarking of assessments between jurisdictions. It will be interesting to see how platforms such as “EnlightenME” from the College of Emergency Medicine in the UK (supported by IFEM), perform when translated between training programs. Will candidates perform equally well around the globe as they work through on-line material? How much will we have to modify content and assessments to match needs in each geographic area?

Some national organizations are now offering international accreditation of training, which should further standardize educational experiences. The UK has a strong tradition of international engagement, with the Royal Colleges having provided exams for international candidates for many years. More recently, the US organizations have started to explore this with both the ACGME (American Council of Graduate Medical Education) and the ABEM (American Board of Emergency Medicine) developing international arms. Countries such as Qatar, Singapore and United Arab Emirates have been exploring accreditation of training programs and exams using these bodies. The accreditation would be under an international arm of the national body. This accreditation will be expensive and beyond the financial capacity of many countries. Nevertheless there are many benefits for countries developing their emergency systems in having accreditation by an international body.

Accreditation by a credible international authority immediately gives status to the discipline at a political and community level. The status of the specialist group amongst peers is also elevated. In addition, the accreditation process acts as a powerful tool to force health services to adequately resource training facilities and workforce. Hopefully the accrediting body can also assist with educational resources including standardized processes, benchmarking and sharing of experience in developing training programs. In the future, it might be that graduates from programs that have international accreditation are more likely to get jobs in other countries and may avoid tortuous entry requirements. It is often asked why IFEM doesn’t undertake accreditation of training and run exams as well. In theory, this is a good idea and could really provide an international benchmark for comparison of training schemes. Additionally, it could allow more free movement of EM physicians between countries. Unfortunately the infrastructure required to do this well is enormous and the process would be very expensive. Unless time was volunteered and travel was donated, the financial risk would be high for IFEM and ultimately may not be worthwhile. The reality is that the larger national organizations have processes and infrastructure already in place that can be modified for international sites. It is therefore easier for these organizations to trial these forms of accreditation and assessment. That is not to say that IFEM will never become involved in accreditation and assessment – but at this stage, it is beyond our current resources.

So, back to my emergency department with a heterogenous group of doctors from varying backgrounds. There is no doubt that when I compare the skill levels, there is a bigger variation than in an emergency department in Australia, where there is much greater standardization of training. However the biggest single determinate of competence and ability is attitude. Given that most doctors who complete medical school are intelligent and have some dedication to their work, keen young doctors will find the answers to clinical problems in spite of the specifics of their training program. For this to happen easily, there should be a culture of learning within the department and access to learning resources.

This article originally appeared in issue 11 of Emergency Physicians International

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