The future of emergency medicine hangs in the balance as the EM community grapples with the ACGME's new Common Program Requirements.
In July 2019, limits on clinical work hours will be taken away from core residency program faculty. The impact of this change is far-reaching and has provoked action by emergency medicine trainees across the country. Core faculty are the foundation of emergency medicine, charged with training the future generation while pushing the specialty forward through scholarship and academic productivity—all while working clinically in the most intense, stressful specialty of modern medicine. Without protected time, core faculty will be unable to complete their mission. The future of emergency medicine hangs in the balance as the emergency medicine community grapples with the new Common Program Requirements.
Upcoming Changes to the Common Program Requirements
At its core, residency training represents the transformation of a medical student to an independent physician. The purpose of the Accrediting Council for Graduate Medical Education (ACGME) is to improve health care by standardizing this process. The general guidelines created by the ACGME for accreditation purposes are known as the Common Program Requirements (CPR). Specifications in these program requirements range from limits on resident duty hours to faculty responsibilities. For unique issues, the ACGME also maintains a dedicated Review Committee for each specialty.
To adapt over time, the CPR undergoes regular revision. Historically, the CPR and Review Committee for Emergency Medicine (RC-EM) requirements have met the needs of emergency medicine by allowing the specialty to protect academic time for core faculty.
This has been accomplished through a specific provision that allows the RC-EM to limit clinical hours for the program director, associate program directors, and core faculty.1
When the new CPR changes go into effect on July 1, this protection will no longer exist.
The greatest threat stems from removal of the provision allowing for the RC-EM to create requirements specific to core faculty.2 This prevents the specialty from creating formal limitations on clinical hours for core faculty and represents a major ideology shift away from protected faculty time. Emergency medicine residents are disturbed by this revision and the downstream impact it will have on the specialty.
Challenges to On-Shift Education
The nature of emergency medicine demands minute-to-minute care, which rapidly diminishes the ability to do anything other than direct patient care on shift. While faculty from other specialties may be able to briefly step away from clinical responsibilities after rounds, the dynamic environment in the emergency department requires that emergency physicians directly care for patients throughout the entire shift.3
The challenge of bringing core education into the emergency department cannot be understated. Unlike inpatient teaching services with mandated caps, there is no way to cap the number of patients presenting to the emergency department. Even in maximum-capacity scenarios in which ambulances are temporarily diverted to other hospitals, the doors remain open for walk-in patients to receive care.
Like unlimited patient caps, the increasingly prevalent phenomenon of emergency department overcrowding places stress on education. While this has led to increased clinical experience for emergency medicine residents and forced the development of innovative teaching methods on-shift, overcrowding results in decreased faculty supervision and further decreases on-shift education.4,5 To make matters more complicated, the literature is clear that both emergency department patient volume and complexity are increasing at a steady pace.6
Finally, clinical productivity measures represent a unique challenge to on shift education. Although important to maximize patient care capacity, pressure to satisfy administrative metrics disincentivizes emergency physicians from dedicating on shift time to resident education. While residents in other specialties often decrease productivity, emergency medicine residents have been shown to both increase productivity and reduce emergency physician staffing requirements.7,8,9,10 By decreasing emergency physician hours and adding resident hours, emergency departments are maximizing productivity while decreasing opportunity for on shift education. Without protected time, there is no way to compensate for this.
Emerging Role of Off-Shift Clinical Education
While all residents have dedicated classroom time, there is substantial evidence that emergency medicine education is best done off-shift.4 One potential explanation for this is that the breadth of the specialty is massive. As the name implies, emergency medicine encompasses a wide scope of low frequency, high risk situations. As other specialties continue to sub-specialize and reduce their individual scope, the emergency medicine scope of practice continues to expand.
Although emergency medicine residents routinely perform most critical procedures in the emergency physician scope of practice, the expectation is that they will be able to perform every possible procedure safely at a moment’s notice once working independently. This level of mastery can only be achieved through off shift education. In fact, simulation training has become a critical adjunct to emergency medicine education for this reason.11,12,13,14 The only way that core faculty can provide this detailed level of training is through protected time.
Impact on Burnout Culture and Wellness
Protected core faculty hours are dedicated to clinical education, research, and administrative work. These activities represent the core of academic emergency medicine and serve as the guiding force for the specialty. Innovation in each of these respective areas is the direct result of protected time. In its absence, emergency medicine stands to lose the momentum it has worked so hard to generate since its inception.
Requiring core faculty to teach and perform scholarly activity without protected time is an unrealistic burden. In fact, there is evidence that excessive faculty work burdens perpetuate burnout culture and incapacitate the ability to effectively support residents during critical points in training.15
The high-intensity shift work of clinical emergency medicine has already proven to cause physician burnout at levels unrivaled by any other modern medical specialty. The unrealistic burden placed by removing core faculty protected time will substantially increase burnout, further contributing to this serious problem at a critically low point in the history of the specialty.16
Workforce Implications in Academic Emergency Medicine
The future of academic emergency medicine is inherently dependent on protected time for core faculty. Historically, the percentage of emergency medicine residents that enter academic emergency medicine is approximately 26%.17 With unlimited clinical hours, expectation to spend uncompensated personal time on academic productivity, and lower pay than alternative positions in community practice, it seems likely that this percentage will significantly decrease.18,19,20
Limiting time protections impairs the ability of faculty to investigate gaps in program inclusion, to enhance residency program diversity, and to mentor residents and students from underprivileged or underrepresented backgrounds. These are factors associated with increased diversity in emergency medicine residency programs.21,22
The loss of protected time will disproportionately impact graduating emergency medicine residents from diverse backgrounds and further exacerbate existing disparities among academic emergency medicine faculty. The cycle will then repeat as emergency medicine trainees from underprivileged or underrepresented backgrounds are less able to find academic mentors from diverse backgrounds.21,22 Interestingly, the proposed CPR specifically requires that programs engage in practices that focus on systematic recruitment and retention of a diverse and inclusive workforce of residents, fellows, and academic faculty.23
To further illustrate this concept, consider the immediate impact that this simple change will have on the livelihood of academic emergency physicians themselves. The Council of Residency Directors in Emergency Medicine (CORD) recently conducted an internal survey designed to assess the opinions of protected time by those directly affected by the change—the program directors, assistant program directors, and core faculty in ACGME-accredited emergency medicine residency programs.
They found that 95% of nearly 200 respondents considered a loss of protected time to be “job threatening” or “career threatening”. Not surprisingly, a similar proportion of respondents felt that the loss of protected time would significantly impair their ability to perform academic duties.24 In this, eliminating protected time for core faculty threatens not only the future of the specialty, but the present, too.
As health care trends increasingly incentivize institutions to redirect priorities toward clinical productivity and revenue, it is now more important than ever for accrediting bodies to uphold the academic duty of residency training. It is imperative to maintain a high standard to ensure that today’s residents are prepared to become tomorrow’s leaders and innovators. For emergency physicians in training, protected faculty time is an absolute necessity. It is the key mechanism through which emergency medicine learners engage with educators and is the only way to achieve the academic progress that will propel the specialty into the future.
1. Common Program Requirements (Residency), I.A.1. Accreditation Council for Graduate Medical Education (2016).
2. Common Program Requirements (Residency), II. B. 4. b. Accreditation Council for Graduate Medical Education (2018).
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4. Lin M, Taira T, Promes S, Regan L. Educational excellence in a crowded emergency department: consensus recommendations from the council of emergency medicine residency directors 2010. J Grad Med Educ. 2011;3(2):249-52.
5. Shayne P, Lin M, Ufberg JW, et al. The effect of emergency department crowding on education: blessing or curse? Acad Emerg Med. 2009;16(1):76-82.
6. Lin MP, Baker O, Richardson LD, Schuur JD. Trends in Emergency Department Visits and Admission Rates Among US Acute Care Hospitals. JAMA Intern Med. 2018;178(12):1708-1710.
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8. Alkhalifah M, Deibel M, Lowry J. The Influence of Emergency Medicine Residents on Emergency Medicine Attending Productivity. West J Emerg Med. 2015 July;16(4.1):S37-S38.
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11. Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB. Residents' Procedural Experience Does Not Ensure Competence: A Research Synthesis. J Grad Med Educ. 2017;9(2):201-208.
12. Mittiga MR, Geis GL, Kerrey BT, Rinderknecht AS. The spectrum and frequency of critical procedures performed in a pediatric emergency department: implications of a provider-level view. Ann Emerg Med. 2013;61(3):263-70.
13. Bucher JT, Bryczkowski C, Wei G, Riggs RL, Kotwal A, Sumner B, McCoy JV. Procedure rates performed by emergency medicine residents: a retrospective review. Int J Emerg Med. 2018 Feb 14;11(1):7.
14. Li S, Setlik J. Critical Procedure Skill Maintenance Through Simulation Based Curriculum in Pediatric Intensive Care Unit and Pediatric Emergency Medicine. Pediatrics. 2018;141(1 MeetingAbstract):322.
15. Jennings ML, Slavin SJ. Resident Wellness Matters: Optimizing Resident Education and Wellness Through the Learning Environment. Acad Med. 2015;90(9):1246-50.
16. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172(18):1377-85.
17. Burkhardt J, Kowalenko T, Meurer W. Academic career selection in American emergency medicine residents. Acad Emerg Med. 2011;18: S48-S53.
18. Goldberg R, Boss RW, Chan L, et al. Burnout and its correlates in emergency physicians: four years' experience with a wellness booth. Acad Emerg Med. 1996;3(12):1156-1164.
19. Kuhn G, Goldberg R, Compton S. Tolerance for uncertainty, burnout, and satisfaction with the career of emergency medicine. Ann Emerg Med. 2009;54(1):106-113.
20. Arora M, Asha S, Chinnappa J, Diwan AD. Burnout in emergency medicine physicians. Emerg Med Australas. 2013;25(6):491-495.
21. Tunson J, Boatright D, Oberfoell S, et al. Increasing resident diversity in an emergency medicine residency program: a pilot intervention with three principal strategies. Acad Med. 2016;91(7):958-961
22. Garrick JF, Perez B, Anaebere TC, Craine P, Lyons C, Lee T. The Diversity Snowball Effect: The Quest to Increase Diversity in Emergency Medicine: A Case Study of Highland's Emergency Medicine Residency Program. Ann Emerg Med. 2019;73(6):639-647.
23. Common Program Requirements (Residency), I. C. Accreditation Council for Graduate Medical Education (2018).
24. Letter from the Council of Residency Directors in Emergency Medicine to Accreditation Council for Graduate Medical Education (2018, November 6). Irving, Texas.