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作为医学教育的一部分，医学院的学生经常在急救部门穿梭。医学目前，在美国有161个急诊医学住院医师项目，该项目中已有许多医学院的学生在急诊部门接受考验。急救部门在一定程度上对学生教育来说是一种独一无二的环境来监督医生，来研究投诉的敏度，滞留时间，并及时处理。在这个典型的教育模式中，医学院的学生呈现了从监督住院人员到急诊部门的典型移位的一个案列。大家都相信的是医学院的学生有效地延迟了滞留时间，就如在呈现和教学的设置中延长护理时间。在急诊部门拥挤的时候，住院时间对员工和管理人员来说是一个有意义的，主要的手段来有效地提升病人护理的质量。
INTRODUCTION介绍
Medical students often rotate through emergency departments (EDs) as part of their medical education. There are currently 161 Emergency Medicine residency programsin the United States, many of which have medical studentsrotating through the ED.1 The ED is a somewhat unique environment for student education as the focus for supervising physicians is often on acuity of complaint, length of stay, and prompt disposition.2,3 In this typical educational model,medical students present cases to the supervising residentor attending who are working a ED typical shift. A common belief is that medical students significantly delay patient length of stay (LOS) as care can be prolonged in the setting of presenting and teaching.4-7 In an era of ED crowding, LOS i s a significant core measure for staff and administrators inproviding efficient patient care.8
In 2007 our medical school instituted a required 2-weekrotation for third-year medical students in the ED. At thesame time, our emergency medicine (EM) residency hopedto improve the training of their residents in the disciplines ofmedical education and evidence-based practice. In light ofthis, a teaching service was created to satisfy the needs of boththe medical school and the residency.
The teaching service is comprised of 1 attending physician,2 third-year residents, and 4 to 6 third-year medical students.The teaching service is present in the ED seeing patients from14:00-19:59 on Mondays, Tuesdays, Thursdays, and Fridays(excluding academic holidays). For 2 hours prior to the start oftheir clinical shift the teaching service meets for small groupteaching. The first hour is resident-led didactics for the medicalstudents. This provides residents with protected time to teachwhile also providing an opportunity to receive feedback ontheir teaching skills from an experienced attending. Duringthe second hour the attending physician presents a topic fromevidenced-based medicine or the “teaching how to teach”curriculum. One day of the week this 2-hour period is spentin simulation where residents lead cases with medical studentinvolvement.9 It is worth noting that the teaching service isnot restricted to low-level acuity patients. Because there is adedicated attending and 2 third-year residents, the teachingservice picks up patients in the same manner as the otherproviders without restrictions on triage level.
Since its creation, the teaching service has expanded.During the 2009-2010 academic year, a total of 162 thirdyearmedical students rotated on the required EM rotation,with approximately two-thirds rotating as part of the teachingservice at University of Colorado Hospital, a large-volumetertiary referral hospital. This study focuses exclusivelyon patient data from the University of Colorado ED, as theteaching service at other sites is organized differently.
Our study investigates the LOS and number of EDpatients seen by the teaching service with students (TWS)when compared to the teaching service without students(TWOS), and when compared to no teaching service (NTS).
METHODS方式
Study Setting 研究设置
Study Population 研究对象
DISCUSSION讨论
This study had 2 key findings. First, median LOS forpatients treated during a shift with TWS was approximately15 minutes longer than shifts with TWOS (an extra physicianteam) and shifts where there was no teaching service (normalED staffing). We would advocate that this is a minimalincrease given the value added in both student and residenteducation from the care of these patients. The presence of ateaching service was also associated with approximately 4more patient evaluations per shift, and the number of patientsseen did not decrease when third-year students were a part ofthe teaching service team.
A handful of studies have examined LOS in EDs in thesetting of medical student education. Generally, previousstudies have shown that students were associated withprolonged ED patient LOS.4-7 A 2009 study by James etal quantified the effects of trainees on LOS when staffingwith a preceptor and found that in their pediatric ED, LOSwas 9% higher in patients seen by trainees.4 Another studyby Gerbeaux et al5 corroborated these findings during amedical student strike and found that during the 4 dayswithout medical students the LOS decreased by 24%. TheJames study correlates well with our own results of a 6.8%increase in LOS of the TWS service as compared to theTWOS. Both studies suggest a reduction in efficiency whenstudents are added to care teams, as evidenced by increasedLOS. However, these data were compiled in the setting of the trainee staffing patients with the attending physician alongsidethe other resident providers. Other studies show no significantchange in LOS under different models of teaching or wereunable to quantify changes on LOS. Our study supports thisfinding; although there is no doubt that there was an effect onLOS, this effect was minimal. Of note, none of these studiesexamine fourth-year medical students, who may contributemore to patient care and LOS considering they have moreclinical training.10-12
Limited research has been done examining the generalflow of the ED in the setting of separating out trainee students.This is the first study to examine the LOS and number ofpatients seen during shifts with and without students on adedicated teaching service. Our study differs from previousresearch in that medical student teaching can be done in amanner that does not tax the ED by significantly changingLOS or number of patients seen.#p#分页标题#e#
There are a few limitations of this study. First, weonly evaluated LOS and number of patients seen duringa specific time period (14:00 – 19:59), which impacts thegeneralizability of our findings to other times of day. Theoptimal study design to measure the effect of the teachingservice on LOS would be to randomly assign the teachingservice to shifts and compare LOS between shifts withand without the teaching service. However, in our settingthis design is not feasible secondary to constraints of thestudent schedule. Given these inherent limitations, we wereunable to evaluate the impact of teaching service on LOSduring other times of day such as early day or night shifts.In addition, volume fluctuation on weekends and holidayswhen the teaching service was not present may also affect thegeneralizability of our results. It is also worth noting that thisstudy looked at a teaching service with third-year medicalstudents who are early in their clinical training; therefore,one may not be able to directly apply these findings to groupsteaching medical students who are further along in theirtraining.. We did not analyze results with regard to calendartime during the academic year, nor were we ableable tofactor in any improvement in students’ efficiency. Lastly, wewere unable to correlate patient acuity levels to the differentsubgroups to determine if the TWS group saw lower acuitylevel patients and if this in turn impacted LOS or number ofpatients seen; however, this would be an interesting area offuture study.
Finally, this model requires an increase in resident andattending coverage, which could increase overall cost for extrafaculty. It is likely that a teaching service without additionalstaff may have a greater effect on LOS and decrease patientthroughput. It is unclear how this study would fare at otherinstitutions since our model requires additional staff to runthe teaching service. We also did not examine fourth-yearmedical students, as at our institution. the third-and fourthyearmedical students rotate in separate entities with thefourth years being considered the level of an “intern,” andtherefore staff their patients as such. During NTS days, thereare no third-year medical students present in the departmentand therefore they are not dispersed among clinical faculty.The fourth-year medical students are always dispersed amongclinical faculty and are not included in the dedicated teachingservice model.
CONCLUSION总结
Further investigation of this teaching model is necessaryto validate the effects of LOS and number of patients seen atother facilities. A prior study reveals the teaching service iswell regarded,12 but to date neither an assessment of student orresident skill has been done nor outcomes studied to evaluatethe effect of a teaching service on patient care.
A teaching service in the ED is a novel educationalmodel that provides dedicated teaching time to both studentsand residents amidst a busy urban academic ED. This studycomprises the first evaluation of LOS and number of patientsseen with the advent of a dedicated teaching service to instructmedical students. The effect of such a teaching serviceincreased the number of patients seen during a shift and had aminimal effect on patient median length of stay.
REFERENCES参考文献
1.FREIDA Online. American Medical Association. Available at:https://freida.ama-assn.org/Freida/user/viewProgramSearch.do AccessedMarch 7, 2013.
2. Thomas HA, Beeson MS, Binder LS, et al. The 2005 Model of theClinical Practice of Emergency Medicine: the 2007 update. AcadEmerg Med. 2008; 15:776–9.
3. The ACGME Outcome Project. ACGME core competencies. Availableat: http://www.acgme.org/outcome/comp/compCPRL.asp. AccessedMarch 20, 2011.
4. James C, Harper M, Johnston P, et al. (2009), Effect of Trainees onLength of Stay in the Pediatric Emergency Department. AcademicEmergency Medicine, 16: 859–865.
5. Gerbeaux P, Ledoray V, Liauthaud H. Medical student effect on emergencydepartment length of stay. Ann Emerg Med. 2001; 37:275–278.
6. Lammers R, Roiger M, Rice L, et al. The effect of a new emergencymedicine residency program on patient length of stay in a communityhospital emergency department. Acad Emerg Med. 2003.
7. Salazar A, Corbella X, Onaga H, et al. Impact of a resident strike onemergency department quality indicators at an urban teaching hospital.Acad Emerg Med. 2001; 8:804-808.
8. Burt C, McCaig L. Staffing, capacity, and ambulance diversion inemergency departments. Adv Data. 2006; 376:1–23.
9. Druck J, Houghland J, Anderson B. Teaching how to teach: a novelteaching rotation. Med Educ. 2011 May; 45(5):525-526.
10. Chan L, Kass L. Impact of medical student preceptorship on EDpatient throughput time. Am J Emerg Med. 1999; 17:41–43.
11. French D, Zwemer F, Schneider S. The effects of the absence ofemergency medicine residents in an academic emergency department.Acad Emerg Med. 2002; 9:1205–1210.
12. Denninghoff KR, Moye PK. Teaching students during an emergencywalk-in clinic rotation does not delay care. Acad Med. 1998 Dec;73(12):1311.
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