An holistic approach

By ahhb
Tuesday, 07 October, 2014

For the Australasian College of Emergency Medicine, the task of improving the way emergency medicine trainees prepare for work as specialists is a focus of the current curriculum review and revision work, writes Mary Lawson.

Image_Assessments_pageThe Australasian College of Emergency Medicine (ACEM) is the peak body for emergency medicine (EM) in Australia and New Zealand and its training program is the pathway through which medical graduates become fully accredited Fellows of the College (FACEMs).
The curriculum review process began in 2009 with a review of the current training program.  This is a standard quality improvement activity of ACEM and indeed of all specialist medical colleges in Australia and New Zealand.  The review was completed over an 18 month period by the Training and Assessment Review Working Group (TARWG). This involved an extensive consultation process, including a widespread call for submissions and a series of focus groups held throughout Australasia. Out of this arose a set of results that were used by TARWG to form the Recommendations for Change.
Supervision-of-a-trainee-carrying-out-patient-assessmentThe Curriculum Revision Project (CRP) was formally launched in December 2011 with the stated aim of producing a revised training program that fulfilled the recommendations proposed from the review. A governance structure was created for the project that divided work up into eight main subgroups, overseen by a steering group. The eight subgroups covered authoring, assessments, teacher training, trainee welfare, progression, accreditation, transition and evaluation, and operations. Great effort was made to ensure that the CRP included members from different geographic locations and a range of backgrounds and experience was represented.
Among the tasks of the CRP, the development of a Curriculum Framework and changes to the assessment suite were identified as key areas of activity.
Emergency medicine is a complex and unique discipline of medical practice. As well as being expert clinicians, today’s specialists are expected to be proficient in a wide range of non-technical skills. In an evolving discipline, it is imperative to update links between training and practice. The CRP has employed an holistic approach to ensure the curriculum is contemporary in both content and method.
Chief drivers
Having filled numerous senior roles within ACEM – including Censor in Chief (Educational Lead position) and President – and played a leading role in the College’s previous Curriculum Review in the mid-2000s, Associate Professor Andrew Singer has been intimately connected to the nuts and bolts of the ACEM training program for more than two decades. For the current CRP he has taken the role of Lead of the Assessments Subgroup and sits on the CRP Steering Group
Singer highlights two main changes in the area of legislation that have driven the need for the revision of the ACEM Training Program. One is the development of the National Registration and Accreditation Scheme which was established by state and territory governments in 2010. The scheme enabled the development of a flexible, responsive and sustainable Australian health workforce. The second change is the accreditation of medical colleges by the Australian Medical Council (AMC).
“Since 2002 the AMC has been accrediting medical colleges based on a need to drive change and encourage best practice in medical education,” says Singer, “It’s also been part of a movement to try and make colleges more aware of the broader external context that they operate in.”
While many drivers for the CRP have been external, Singer notes that a significant internal momentum has also existed for some time from Fellows and trainees wanting the current training program to be improved.
WBA-Training-Videos---Giving-Feedback-in-the-WorkplaceFraming the future
The new Curriculum Framework covers eight domains of practice mapped against the stages of training, with expected levels of performance outlined for each stage in each domain. The eight domains are: medical expertise; prioritisation and decision making; communication; teamwork and collaboration; leadership and management; health advocacy; scholarship and teaching; and professionalism.
The domains draw on the CanMEDS framework developed by the Royal College of Physicians and Surgeons of Canada (RCPSC) during the 1990s. This method for categorising the knowledge, skills and attributes of specialist physicians has been adopted and adapted by many medical colleges around the world, including those in Australia and New Zealand.  ACEM incorporated a modified version of it into its curriculum review of the mid-2000s but in the current curriculum revision process additional work has been done to integrate it into the context of contemporary emergency medicine across Australasia.
Elizabeth Mowatt is an ACEM Fellow who is the current Chair of the Authoring Subgroup – the part of the CRP charged with developing content for the new curriculum – and also served as a member of the education advisory group that was formed at the same time as TARWG.
In each domain the expected levels of performance are split up into key topics, Mowatt says. For instance, in the Communication domain the topics are: principles of effective communication; communication with patients, carers and the general public; and communicating with colleagues. Each key topic is split into sub-topics which define the learning outcomes expected in that particular area. Trainees focusing on the principles of effective communication are expected to develop their skills and knowledge of the foundations of good communication, the barriers to effective communication, conveying bad news, effective written communication and intercultural communication. Within each sub-topic a number of specific learning outcomes are detailed, clarifying exactly the specific performance requirements trainees must reach as they progress through the training program.
“Working on this has been fantastic but unbelievably time consuming!” Mowatt laughs. “We spent days and days writing and rewriting the learning outcomes so they’d be easy to understand. I have training in education but until you work at this level of detail you don’t realise the amount of work that goes into something like this.”
Mowatt notes the authoring subgroup worked hard to write learning outcomes that were easy to understand. It’s this effort to create consistent language which she hopes will lead to the Curriculum Framework being used widely by all ACEM members throughout their career and not just by trainees and supervisors during training. This framework embodies the core of the emergency medicine skillset in simple, clearly defined terms, creating a roadmap that everyone can follow during training and throughout their consultant career via continuing professional development.
“When I was in the process of writing,  I went to work one day and was watching a trainee having an interaction with a patient,” Mowatt recalls. “I could see he was struggling but couldn’t put my finger on exactly what  was missing and how to help him. Later  I was able to go into the set of learning outcomes I’d been writing – around communication – and find the right  language to use to give him  feedback.”

“Since 2002 the AMC has been accrediting medical colleges based on a need to drive change and encourage best practice in medical education,” says Singer, “It’s also been part of a movement to try and make colleges more aware of the broader external context that they operate in.”

In the workplace
To align to the new curriculum, the process by which emergency medicine trainees are assessed is also being changed.
One of the assessment changes planned is the introduction of Workplace- based Assessment (WBA). A commonly used form of assessment in medical education, WBAs incorporate short periods of observation and/ or discussion with a trainee in a real life clinical environment, followed by structured feedback and a rating of the trainee’s performance during a specified period.
The Emergency Medicine WBAs introduce a set of tools to the ACEM Training Program that bring elements of a trainee’s everyday ‘on the floor’ activity into the formal assessment process. For instance, one WBA instrument, Direct Observation of Procedural Skills (DOPs), involves an assessor observing a trainee while they carry out a specific clinical procedure. The trainee’s performance is rated and feedback is provided. Other tools include Shift Report (observing a trainee’s performance throughout a clinical shift) and Mini-Clinical Evaluation Exercise (assessing them as they perform a focussed clinical task during a specific patient encounter). The opportunity for trainees to integrate feedback into their everyday practice is expected to lead to an increase in the overall quality of care they deliver to patients.
Development of WBAs has been supported by a trial which ran from March to June 2014.  Over 100 Emergency Departments throughout Australasia participated. A variety of resources were made available to support trial participants, including interactive online training modules. The information gathered from the trial has proved invaluable for a number of reasons. It provides the first objective data which can be used to appropriately benchmark WBA tools in the unique context of Australasian emergency medicine. It also gives Fellows, trainees and other ED staff the opportunity to get some ‘real-life’ practice in completing WBAs in their own environment. Participants registered their results via an online trial WBA system and the performance of this, the assessment forms, resources and other operational system elements used in the trial will be evaluated and integrated into the formal WBA system scheduled for implementation in the 2015 training year.
Beyond the horizon
At time of writing the CRP is at a very busy and exciting stage. Further development is underway on the Curriculum Framework with a second version planned for release later this year. Next year will see the launch of the revised training program.  Following implementation, continuous quality improvement of the training program will take place.
While being realistic about the challenges that lie ahead, Mowatt for one feels good about what’s been achieved so far. The benefit for future trainees and for the College as a whole from the new curriculum will be considerable. Personally, too, she has found the experience transformative.
“This is a huge project and I’m in awe of the amount of planning that’s gone into it,” she says, “It’s been a great honour to work with my colleagues.”

Mary Lawson
Mary-LawsonMary Lawson has experience in medical education spanning more than two decades in both the undergraduate and postgraduate arenas. She has developed a variety of higher degree programs in health professional education and has also coordinated large-scale national research projects in medical education in both Australia and the UK. She is Director of Education at the Australasian College for Emergency Medicine (ACEM). In this role she is engaged with a large- scale curriculum revision which includes the implementation of a comprehensive system of workplace- based assessment and large-scale changes to the formal assessments

The Australasian College for Emergency Medicine (ACEM) is the not-for-profit organisation resonsible for training emergency physicians and advancement of professional standards in emergency medicine in Australia and New Zealand. As the peak professional organisation for emergency medicine in Australasia,  has a significant interest in ensuring the highest standards of medical care for patients are maintained in emergency departments across Australia and New Zealand.
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