A Stepping Stone to Standardization

   The declaration last year of EMS as an officially recognized medical subspecialty-so decreed by the American Board of Emergency Medicine (ABEM), one of 24 medical specialty boards under the American Board of Medical Specialties (ABMS)-was met with hosannas across the prehospital community. But for the programs actually training the medical directors of tomorrow, now comes the hard part.

   Among the ramifications of the long-sought decision, EMS fellowship programs could face hurdles to meet new requirements for accreditation by the Accreditation Council for Graduate Medical Education (ACGME).

Background

   ABMS' member boards represent 145 recognized medical specialties and subspecialties. Under ABEM, EMS joins medical toxicology, pediatric emergency medicine, sports medicine, undersea/hyperbaric medicine, and hospice/palliative medicine.

   "Subspecialty certification is one of the stepping stones toward standardizing EMS care in the United States," says Jane Brice, MD, MPH, an associate professor of emergency medicine and director of the EMS fellowship program at the University of North Carolina, who led the team writing the new fellowship curriculum.

   "When you standardize the training and knowledge base EMS medical directors bring to their systems, you create a foundation on which to build. Going forward, EMS medical directors who are board certified in EMS will have had the same training, based on a standardized curriculum, and will have all passed the same test, which guarantees a foundation of knowledge. That will lead to more cohesiveness and interoperability between systems."

   ABEM will develop and administer the certification exam for graduates of accredited fellowship programs, which is expected to be ready in 2013. In the meantime, leaders of the EMS subspecialty effort have been working out exactly what those fellows will learn.

   EMS already had a fellowship curriculum and supporting core content, but that was developed in 1994 and thus outdated. Both components needed revamping to be more clinical and current.

   A team led by Johns Hopkins' Michael Millin, MD, rewrote the core content, and once ABEM signed off on that, Brice's group set the curriculum. The format they utilized mirrored the four volumes of the NAEMSP's Emergency Medical Services: Clinical Practice and System Oversight text: clinical aspects of prehospital medicine; medical oversight of EMS; quality management and research; and special operations (see Figure1).

   In delivering that curriculum, accredited fellowship programs will have to meet requirements of the ACGME. And while those are still officially under development, an early draft version provides an idea of what they might entail.

   They describe desired fellowship outcomes and set minimum requirements for fellows, program directors and faculty. Notably, they require of fellowship institutions instruction in a broad range of areas pertinent to EMS-not only expected fields like resuscitation, critical care, trauma and infectious disease, but also areas like air medical services, psychiatry and ophthalmology, which some fellowship programs may not currently cover.

   "Our fellowship programs are currently homegrown, so they build on the strength of their institution," says Brice. "For instance, your institution may not have an aeromedical program, so you're not able to provide your fellow with training in aeromedical systems.

   "In setting out what an EMS fellow needs to know," Brice continues, "the EMS fellowship curriculum will require that fellowships not necessarily develop those expertises or specialties, but at least create agreements with other institutions that can provide fellows with that information, so that every fellow graduating from a fellowship program has the same foundation of knowledge."

   There's no guidebook for this, and fellowship programs are going to encounter a variety of challenges in making their changes. One resource that might assist is the newly formed Council of EMS Fellowship Directors created at this year's NAEMSP annual meeting and chaired by David Cone, MD, director of the EMS fellowship program at Yale. It will facilitate sharing valuable ideas and best practices as they're identified.

   "I think each fellowship is going to have its unique difficulties in meeting the requirements," says Brice. "I don't think anybody's going to skate through without challenges. Working together, we hope to make this as painless as possible. But there's going to be pain.

Our Time Finally Comes: What Tipped the Scale?

   The quest for EMS subspecialty certification began in the 1990s but failed when ABEM decided the field was too administrative and lacked a unique body of knowledge and strong scientific underpinnings.

   By 2010, those views had changed. What changed them?

   "I think part of it was just the maturation of EMS," says ABEM President Mark Steele, MD. "Over the years, the interest in EMS has grown to where there's now really a significant critical mass of physicians practicing in the field. NAEMSP has over 800 physician members, and there are currently something like 62 EMS fellowships. Those are obviously not ACGME-accredited, but it's assumed many will be applying.

   "Also there's the research base within EMS," Steele continues. "Over the years, there have been thousands of articles published. And I think over time the extension of practice into the field has become more significant.

   "Part of the challenge with any new subspecialty is that you have to convince ABMS that the field of practice is distinct and unique. In the early days, to differentiate standard emergency medicine care in a hospital from that in the field, from a clinical perspective, was probably more difficult. I think today it's much clearer and the extension of clinical practice into the field is very well delineated."

FIGURE 1: Curriculum Format

   Intentionally mirrors the four volumes of the NAEMSP text Emergency Medical Services: Clinical Practice and System Oversight.

   Clinical Aspects of Prehospital Medicine

• Time/Life Critical Events
• Injury
• Medical Emergencies
• Special Clinical Considerations

   Medical Oversight of EMS

• Medical Oversight
• EMS Systems
• EMS Personnel
• System Management

   Quality Management and Research

• Research

   Special Operations

• Mass Casualty Management
• Chemical/Biological/Nuclear/Explosive(CBRNE)
• Mass Gathering
• Disaster Management
• EMS Special Operations

FIGURE 2: Sample Curriculum Element

   1.1 Time/Life Critical Events

   Goals and Objectives:

   At the completion of fellowship training, the EMS physician will be competent to:
1. Recognize patients in the prehospital environment with time/life critical events
2. Perform procedures necessary for patient stabilization and treatment in the prehospital environment
3. Assess and manage the airway in the prehospital environment
4. Assess and manage breathing through physical examination, measurement of oxygen saturation and end-tidal CO2 monitoring
5. Assess and manage circulation and delivery of medication
6. Assess and manage the differential diagnosis to find and treat reversible causes of time/life critical events

   Evaluation and Assessment Methods:

1. Direct observation of patient assessment and treatment skills in the prehospital setting by program director or faculty supervisor
2. Structured patient simulations
3. 360° feedback from faculty, allied health personnel, patient
4. Retrospective chart review