Emergency Department Crowding: The Effect on Resident Education

doi:10.1016/j.annemergmed.2004.12.011

Annals of Emergency Medicine

Volume 45, Issue 3, March 2005, Pages 276-281

https://doi.org/10.1016/j.annemergmed.2004.12.011 Get rights and content

Introduction

A recent study analyzed the amount of time emergency medicine residents spend with their faculty supervisors when they work together in the emergency department (ED).¹ The authors found that attending physicians observed the resident providing direct patient care during only 3% of the resident's total work time. This is consistent with a previous report² and occurred in a setting of one resident working with one attending physician. Indirect observation, including tasks such as presenting patient information, constituted another 11% of the resident's work time. The authors questioned whether observation time could be increased by faculty education or whether faculty were already at their capacity. They recommended that administrators who develop resident assessment techniques be cognizant of the time limitations faculty have while working clinically in the ED.

We suspect that these “time limitations” are caused in part by ED crowding. Many EDs are struggling with increased patient volumes and worsened crowding; words like “gridlock,” “boarded,”³ “holding time,”⁴ and “trolley waits”⁵ have become part of the lexicon of emergency medicine in a variety of countries. In the United States, ED crowding became more prominent in the early 1990s, at teaching centers; by the late 1990s, it was reported in community, suburban, and rural hospitals.⁶ ED crowding has also been documented in Canada,7, 8 the United Kingdom,⁵ Spain,⁹ Australia,¹⁰ and Taiwan,¹¹ using a variety of techniques and definitions. Numerous causes have been postulated and investigated (Figure). As ED crowding threatens to shift from a discussion point to a part of ED practice, it is timely to examine the likely effect it has on emergency medicine residency education.

Section snippets

Education in the ED

Education may be subdivided into teaching and learning, both of which are likely to be affected by crowding. Although there is little to debate on the importance of teachers in residency education, learners also contribute to the process¹² by actively interacting with their teachers, stimulating the discussion, and propelling the exchange into new areas. In this article, we will outline the process of effective clinical teaching and the role of the learner, examining each through the lens of

Optimize the teacher-learner interaction

Optimizing the teacher-learner interaction entails listening to the learner, asking questions, and leading the learner to conclusions rather than supplying them. This principle may be threatened by crowding for several related reasons. First, increasing ED volumes associated with crowding6, 34, 35 limit the time faculty have to engage the resident in these ways. We postulate that with so many patients needing evaluation and treatment, the attending physician may not have time to question the

The role of the learner

Clearly, many of the causes of ED crowding lead to a common pathway that influences teaching: not enough time. Whether it is in the ambulatory care setting³³ or in the ED,³⁶ teaching does take some time. Another prerequisite of effective ED teaching is a receptive learner.¹² Trainees have 6 general competencies to acquire, defined in 1999 by the Accreditation Council for Graduate Medical Education (ACGME): patient care, medical knowledge, professionalism, systems-based practice, practice-based

Potential solutions

The solutions to ED crowding are mostly systems-based, and thus beyond the direct influence of the individual emergency medicine resident. However, there are several small steps that may be taken to mitigate the effects of crowding on resident education. Effective ED teachers often use prepared resources, such as a file of ECGs, a familiar approach-based textbook, Web-based tutorials and libraries, or visual diagrams.¹² In a gridlocked ED, residents may evaluate these resources while the staff

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Cited by (48)

Optimizing the interaction between residents and attending physicians
2021, European Journal of Operational Research
We analyze how attending physicians should allocate their time between the residents they supervise and their own responsibilities. Under the assumption that a holding cost is incurred when residents and patients wait for a conference with the attending physician, we show that there are only two policies that could maximize the long-run average reward. Namely, it is optimal for the attending physician to start having consultations with the residents either when the residents can no longer examine new patients or as soon as there is a patient ready for conference. Furthermore, we show that the optimality condition is a simple threshold on the holding cost. We then characterize when each of these policies is profitable and the optimum number of residents (supervised by the attending physician) under each policy. We conclude that if a health care facility operates with the optimal number of residents, the two policies become the same and it is always optimal (and profitable) for the attending physician to start conferences with the residents as soon as there is a patient waiting.
Factors Affecting Emergency Department Crowding
2020, Emergency Medicine Clinics of North America
Emergency Medicine Resident Self-assessment of Clinical Teaching Compared to Student Evaluation Using a Previously Validated Rubric
2018, Clinical Therapeutics
Citation Excerpt :
As ED shifts rarely permit consistent, dedicated time for educational sessions, the study of teaching in this environment has proven to be difficult.4 Most research has examined the dynamic between faculty and residents.2 One such prior study investigating the efficacy of teaching by attendings from residents' perspective validated a rubric, known as the ER Scale, to assess clinical teaching in the ED.5
The quality of clinical teaching in the emergency department from the students' perspective has not been previously described in the literature. Our goals were to assess senior residents' teaching ability from the resident/teacher and student/learner viewpoints for any correlation, and to explore any gender association. The secondary goal was to evaluate the possible impact of gender on the resident/student dyad, an interaction that has previously been studied only in the faculty/student pairing.
After approval by an institutional review board, a 1-year, grant-funded, single-site, prospective study was implemented at a regional medical campus that sponsors a 4-year dually approved emergency medicine residency. The residency hosts both medical school students (MSs) and physician's assistant students (PAs). Each student and senior resident working concurrently completed a previously validated ER Scale, which measured residents' teaching performance in 4 categories: Didactic, Clinical, Approachable, and Helpful. Students evaluated residents' teaching, while residents self-assessed their performance. The participants' demographic characteristics gathered included prior knowledge of or exposure to clinical teaching models. Gender was self-reported by participants. The analysis accounted for multiple observations by comparing participants' mean scores.
Ninety-nine subjects were enrolled; none withdrew consent. Thirty-seven residents (11 women) and 62 students (39 women) from 25 MSs and 6 PA schools were enrolled, completing 517 teaching assessments. Students evaluated residents more favorably in all ER Scale categories than did residents on self-assessments (P < 0.0001). This difference was significant in all subgroup comparisons (types of school versus postgraduate years [PGYs]). Residents' evaluations by type of student (MS vs PA) did not show a significant difference. PGY 3 residents assessed themselves higher in all categories than did PGY 4 residents, with Approachability reaching significance (P = 0.0105). Male residents self-assessed their teaching consistently higher than did female residents, significantly so on Clinical (P = 0.0300). Students' evaluations of the residents' teaching skills by residents' gender did not reveal gender differences.
MS and PA students evaluated teaching by EM senior residents statistically significantly higher than did EM residents on self-evaluation when using the ER Scale. Students did not evaluate residents' teaching with any difference by gender, although male residents routinely self-assessed their teaching abilities more positively than did female residents. These findings suggest that, if residency programs utilize resident self-evaluation for programmatic evaluation, the gender of the resident may impact self-scoring. This cohort may inform future study of resident teaching in the emergency department, such as the design of future resident-as-teacher curricula.
Medical student perceptions on the instruction of the emergency medicine oral case presentation
2015, Journal of Emergency Medicine
Citation Excerpt :
There are chronic time limitations, frequent interruptions, and lack of physical space for teaching in academic EDs (16–18). Just a few critically ill patients may absorb the full attention of the instructor for long periods of time (19). There are additional tasks that only attending physicians can perform at many institutions.
The emergency medicine oral case presentation (EM OCP) is the clinician’s communication tool to justify whether urgent intervention is required, to argue for ruling out emergent disease states, and to propose safe disposition plans in the context of triaging patients for medical care and prioritization of resources. The EM OCP provides the representation of the practice of emergency medicine, yet we do not know the current level of effectiveness of its instruction.
We aimed to document medical student perceptions and expectations of the instruction of the EM OCP.
We surveyed medical students from five institutions after their emergency medicine clerkship on their instruction of the EM OCP. Analysis included univariate descriptive statistics and chi-squared analyses for interactions.
One hundred fifty-five medical students (82%) completed the survey. Most medical students reported the EM OCP to be unique compared to that of other disciplines (86%), integral to their clerkship evaluation (77%), and felt that additional teaching was required beyond their current medical school instruction (78%). A minority report being specifically taught the EM OCP (37%), that their instruction was consistent (29%), or that expectations of the EM OCP were clear (21%). Respondents felt that brief instruction during their orientation (65%) and reading with a portable summary card (45%) would improve their EM OCP skills, whereas other modalities would be less helpful.
This study identifies a need for additional specific and consistent teaching of the EM OCP to medical students and their preference on how to receive this instruction.
Does ED crowding decrease the number of procedures a physician in training performs? A prospective observational study
2012, American Journal of Emergency Medicine
The aim of the study was to determine whether the number of procedures performed by residents and medical students in the emergency department (ED) is affected by ED crowding.
In this single-center, prospective, observational study, standardized data collection forms were completed by both trainees and supervising emergency physicians (EPs) at the end of each ED shift from August 2009 to March 2010. Shifts with no trainees were excluded. All procedures that were offered to a trainee were recorded as well as the number of potential ED procedures that were, instead, referred to a consulting service. Emergency department crowding was measured in 2 ways: ED length of stay (LOS) and the EP's assessment of crowding during the shift. Poisson regression was used to assess the adjusted effect of ED crowding on the number of trainee procedures performed as well as on the number of procedures given away.
There were 804 procedures performed by 113 trainees during 647 trainee shifts. Medical students comprised 51% of trainees. Median number of procedures performed per shift was 1.0 (Fine interquartile range, 0-2.0). Emergency department crowding was not associated with the adjusted number of procedures trainees performed using either the EP's assessment of crowding (P = .52) or ED LOS (P = .84). Emergency department crowding was associated with an adjusted 256% increase in the mean number of procedures given away (P = .02) when measured using physician assessment but was not associated with crowding when assessed using ED LOS (P = .06).
Crowding was not significantly associated with the number of procedures availed to ED trainees. In patients being considered for admission, however, when the managing EP felt that it was crowded, there was an association with giving procedures to consulting services.
Analysis of current situation of Chinese health care reform by studying emergency overcrowding in a typical Shanghai hospital
2012, American Journal of Emergency Medicine

View all citing articles on Scopus

Funding and support: The authors report this study did not receive any outside funding or support.

Reprints not available from the authors.

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Residents' PerspectiveEmergency Department Crowding: The Effect on Resident Education

Introduction

Section snippets

Education in the ED

Optimize the teacher-learner interaction

The role of the learner

Potential solutions

First page preview

Am J Emerg Med

Ann Emerg Med

Lancet

Am J Emerg Med

Ann Emerg Med

J Emerg Med

Am J Emerg Med

J Emerg Med

Emerg Med Clin North Am

J Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

Ann Emerg Med

An evaluation of emergency medicine resident interaction time with faculty in different teaching venues

Acad Emerg Med

Observation of emergency medicine residents at the bedside: how often does it happen?

Acad Emerg Med

Can good bed management solve the overcrowding in accident and emergency departments?

Emerg Med J

Frequent overcrowding in US emergency departments

Acad Emerg Med

Emergency department overcrowding following systematic hospital restructuring: trends at twenty hospitals over ten years

Acad Emerg Med

Decreased health care quality associated with emergency department overcrowding

Eur J Emerg Med

Entry overload, emergency department overcrowding, and ambulance bypass

Emerg Med J

Residents' Perspective
Emergency Department Crowding: The Effect on Resident Education