Council of Emergency Medicine Residency Directors

RRC-EM Update and Information for EM program directors

The following is an update on the fall 2005 activities of the RRC-EM, with an emphasis on the information most relevant to EM program directors. Most of this material was covered in the RRC-EM presentation to CORD made by Larry Sulton at the CORD meeting held at the ACEP Scientific Assembly in Washington, D.C. in September 2005. Please also see the RRC-EM update in the previous CORD newsletter for additional information.

1. Accreditation activity: There are currently 134 RRC-EM accredited EM residency programs, and 35 accredited EM subspecialty fellowship programs. At the fall 2005 RRC-EM meeting, 52 EM programs were reviewed, along with 6 Medical Toxicology programs, 2 Pediatric EM programs, and one Undersea and Hyperbaric Medicine program. One new EM program was approved – the University of Florida at Gainesville. David Seaberg, M.D., is the Department Chair and Keith Ferguson, M.D. is the new program director. The spring 2006 RRC-EM meeting will be held this coming week in Tucson, AZ on February 17-19, with several prospective EM programs on the agenda for review, and we will update CORD shortly as these reviews transpire.

2. The RRC-EM periodically reviews and revises the subspecialty area program requirements, and it is currently proceeding with review and revision of both Medical Toxicology and Pediatric EM. Over the past year, the committee has reviewed and undertaken draft revisions to the Medical Toxicology program requirements that are relatively minor. We have approved these changes as a Committee, and they have currently been distributed to organizational stakeholders within Emergency Medicine and to stakeholders in other specialties that sponsor Medical Toxicology (Pediatrics, Internal Medicine, Preventive Medicine) for review and comment. The Pediatric EM program requirements have been extensively reviewed and revised, with agreement on changes approved by the committee. Currently, there is discussion between the RRC-EM and the RRC-Peds on these changes in order to come to consensus and support from both RRC's. Following joint approval by both RRC's (hopefully this spring), these revisions will be sent to stakeholders in both specialties for review and comment.

3. The ACGME Monitoring Committee, which oversees all of the RRC's, formally reviewed the activities of the RRC-EM, and granted 5 years continued accreditation (i.e. delegated authority from the ACGME to continue accreditation activities for EM programs). The RRC-EM was commended for its ability to work well with EM program directors and EM organizations within the specialty, for integration of the ACGME competencies with the Model of Clinical Practice of Emergency Medicine, the RRC-EM 8 year accreditation pilot project, and the use of program guidelines to communicate RRC-EM expectations to program directors. At our next review in 5 years, we will be expected to address 3 issues: Update on experience with the 8 year pilot project, work on creating a systematic approach to collecting procedural and resuscitation data from programs, and address the fact that 50% of the curriculum occurs in specialties other than EM, "outside of the control of EM program directors". We have seen this as desirable flexibility for programs, to allow you to choose the best experiences locally for your training program, and we hope to be able to educate the Monitoring Committee on this point.

4. Some of the EM Program Guidelines underwent minor revisions:
   • Conference attendance: Two things here. First, language has changed slightly on the conference attendance policy. "The program should require that residents, on average, participate in at least 70% of planned educational experiences". This revision addresses the recent discussion on the CORD listserve, and makes it clear that the standard is a 70% average across all residents, no 70% for each resident. Also, there are an increasing number of instances of EM programs not meeting conference attendance requirements who require their residents to cover conferences in the ED. The committee feels that this is within EM department control, and therefore is legitimately a citation to programs.

   • Resident survey information: With the advent of the resident survey, the RRC-EM is challenged as to what to do with this information. We were advised by the ACGME that across RRC's, if 15% of residents indicate a problem on a specific survey question, this may be grounds for a citation and a request to the program to look into this area. For those citations with institutional implications (i.e. duty hours on off service rotations, need for additional ancillary support, contract issues), RRC's are now expressly asking the institutional DIO to assist the program in addressing the citation. For EM duty hours violations, we know that the vast majority of these are on off service rotations and not in the ED. This new procedure allows DIO's to effectively address these problems and help EM program directors.

   • Scholarship guidelines: Guidelines changed under individual core faculty productivity: "A minimum of 80% of designated core faculty members must demonstrate at least one piece of scholarship per year as noted within the program requirements (previously 100% of core faculty had to meet this requirement). This allows the committee to not cite programs for inadequate scholarly activity in programs with good research output just because of 1 or 2 faculty that do not meet the requirement.

   • Core competencies: With the PIF now requiring completion of the core competency addendum, the RRC-EM is challenged as to what the criteria should be for citations. The ACGME has now expressed expectations that programs are providing education on the General Competencies to program faculty and residents, and that some implementation of data collection relative to the competencies (checklist of live performance, 360 degree evaluation, etc) related to the competencies must be in place. This had not existed previously, but becomes the threshold for a citation in this area.

5. With the issue of handling resident survey data noted (#3B above), the RRC-EM has formally asked CORD to review the Resident Survey, and to make suggestions for improving the questions. CORD president Pam Dyne has convened a Task Force to do this, consisting of the CORD Board and selected members whose programs were reviewed in the past year. This task force has corresponded electronically and provided much raw feedback on potential changes. We should be able to produce a report to the RRC this next week on feedback from CORD to be used in modifying and improving the survey. One of the lessons of this review and feedback process is that resident response to many of these questions could be improved if the program spends a little time at the outset with the residents (particularly the EM1's) to make sure they understand that the program has semiannual review, has a process for confidential feedback by residents to faculty, presentations on patient safety and fatigue/wellness, etc. (i.e. things that exist but that they have not yet seen as first year residents, so that they may answer affirmatively on the survey).

   The survey does contain a few EM specific questions, including:

   How many faculty attend/participate in weekly conferences?
   Does your program provide you with an opportunity to:
        - perform an appropriate number of procedures to be competent?
        - direct an appropriate number of major resuscitations to be competent?
         - become a competent EM physician?

6. ACGME RRC-EM 8 year pilot project: So far, 34 programs have been invited to participate in the pilot, and all have agreed to do so. Please see the description of the pilot project in the previous RRC-EM report in the last CORD newsletter. At the end of the fall 2005 RRC-EM meeting, these 34 programs complete the number of participating programs that can be used for the pilot project. We anticipate that when the pilot is evaluated by the ACGME monitoring committee in 12-18 months, the committee will be able to expand enrollment to more programs.

7. The committee recently reviewed the composition of the appeals panel, list of specialist site visitors, list of programs with upcoming site visits, and program director changes. Frank Counselman rotates off of the committee in February 2006, but no other changes are anticipated soon. Congratulations to Frank for 6 years of excellent service to the committee and for his many contributions to the ongoing projects and initiatives of the RRC-EM !!!

Louis Binder, MD
Lsbinder688@pol.net
MetroHealth Medical Center

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