A Transatlantic Comparison of Training in J Accid Emerg Med: First Published As 10.1136/Emj.15.3.175 on 1 May 1998

J7Accid Emerg Med 1998;15:175-180 175

A transatlantic comparison of training in J Accid Emerg Med: first published as 10.1136/emj.15.3.175 on 1 May 1998. Downloaded from emergency medicine

J P Wyatt, J E Weber

Abstract The emergency physician: from school to The system of training in accident and specialist training emergency (A&E) medicine in the United The education structure before the start of Kingdom is at a critical and much earlier specialist postgraduate medical training in the stage of development than in the United USA differs considerably from that in the States. Transatlantic comparison offers United Kingdom. Figure 1 compares the typi- the opportunity to explore possible ways of cal routes taken to become an independent improving training in the United King- trained practitioner in emergency medicine dom. Comparison revealed deficiencies in (termed an "attending physician" in the USA, the UK training system in the following: a "consultant" in the United Kingdom). prehospital care training, formal theoreti- Entry into medical school in the USA is pre- cal teaching, close supervision in a clinical ceded by four years at undergraduate college. setting, and in-service training examina- During this time, it is possible to study any one tions. Implementation of measures de- of a variety of "major" subjects, but to apply for signed to address these deficiencies would medical school it is necessary to also take cer- enhance UK training in A&E medicine. tain core classes (for example, chemistry, biol- (7Accid Emerg Med 1998;15:175-180) ogy, physics, and mathematics). The medical school course in the USA lasts Keywords: training; USA; emergency medicine four years. Broadly speaking, the structure of the course is similar to the traditional British, in that the first two years are spent largely in From humble origins, emergency medicine in the classroom and the last two years are spent the United States has established itself as a largely in university hospitals doing clinical highly attractive specialty. As it has matured, so rotations. Interestingly, emergency medicine is has the training programme for doctors enter- not a mandatory rotation for graduation from ing the specialty. The first residency pro- some American medical schools. However, a gramme in emergency medicine was intro- medical student wishing to successfully apply duced at the University of Cincinnati in 1970; to join an emergency medicine residency will http://emj.bmj.com/ by 1996 the number of programmes had almost certainly need to demonstrate that he increased to 127, with an annual intake of spent some time in the emergency department. more than 1000 residents.1 2 In the United Kingdom, most students enter In the United Kingdom, the equivalent spe- a five year medical school course after second- cialty of accident and emergency (A&E) medi- ary school aged 18 years and obtain a medical cine is currently in a phase of rapid develop- degree (MB ChB or equivalent). Some extend ment. Following the inception of the Faculty of the course by a year to study a preclinical sub- on September 29, 2021 by guest. Protected copyright. A&E Medicine in 1993 and the introduction of ject in more depth and obtain a BSc or B Med Calman proposals, specialist registrar training Sci degree. After successfully completing a in A&E is also developing rapidly.3 I Indeed, it mandatory house officer year comprising six months of surgery and six months of medicine, is evolving in a not dissimilar fashion to that the junior doctor becomes "fully registered" seen previously in the USA. and usually enters a period of two or three In its current phase of rapid development, Accident and years of general professional training. A&E in the United Kingdom faces a consider- Emergency Department, Royal able challenge in determining the optimal Infirmary, Lauriston length and structure of training programmes Entry into specialist training Place, Edinburgh and the best form of associated examinations. Would-be emergency physicians in the USA EH3 9YW, UK A critical comparison of training in emergency enter a residency programme by applying to J P Wyatt medicine in the USA with that in the United the National Resident Matching Program. The Kingdom provides an excellent opportunity for process involves both applicants and emer- Section of Emergency gency programmes ranking each other in order Medicine, University the exchange of ideas, thus enabling the of current systems to be enhanced. However, of preference, enabling an appropriate Michigan Medical "match" to be made. The of School, 1500 East there are certain limitations to such a compari- majority applicants are final medical a minor- Medical Center Drive, son. In particular, differences in specialist year students, Ann Arbor, Michigan are residents* trained in other training need to be interpreted in the light of ity previously 48109 - 0303, USA J E Weber transatlantic differences both in previous training and in emergency health care systems. *Throughout this article, the term "resident" refers to a junior Correspondence to: Interestingly, despite these differences, the role doctor training in emergency medicine in the United States. Mr Wyatt. of the emergency physician in the USA is in Similarly, the term "registrar" refers to a specialist (career) registrar training in accident and emergency in the United Accepted for publication many ways remarkably similar to that in the Kingdom. The term "emergency medicine" is used inter- 1 December 1997 United Kingdom.5 changeably with accident and emergency medicine. 176 Wyatt, Weber

enabling more comprehensive patient care to US system UK system J Accid Emerg Med: first published as 10.1136/emj.15.3.175 on 1 May 1998. Downloaded from be directly or indirectly managed by fully Optional nursery school Optional nursery school trained specialists.7 8 Emergency medicine in (3-5 years) (3-5 years) the USA is, for a variety of reasons, a popular career choice.2 As a result, the supply of poten- I tial trainees has outstripped demand, causing Grade school/high school Primary and secondary schoole fierce competition and ensuring that most (5-18 years) (5-18 years) training positions are easily filled.' " In the United Kingdom, competition for many career registrar posts is such that many trainees are Undergraduate collegea University medical schoolf now looking to try to obtain extra experience (19-22 years) (18-23 years) and research to secure entry. Paradoxically, considering the arguments driving recent changes in specialist registrar training, if this [extra year option BSc or B Med Scil situation continues to develop, it will actually prolong training.3" The developing bottleneck at the point of entry into United Kingdom House officer in medicine and surgery A&E training needs to be addressed, although (23-24 years) the problem has been eased to a certain extent by regulations allowing some time spent in a I "locum against training" post to count towards Medical schoolb Senior House Officerg training. (23-26 years) = general professional training (24-27 years Overall length of training I The most obvious difference in training between the USA and United Kingdom relates Residency trainingC Specialist registrar in A&Eh to the of (27-31 years) (27-32 years) length postgraduate training. Seventy per cent of American residency programmes last three years and begin in the first postgraduate year, although 20% are aimed at resi- [extra 1-3 years option fellowship +/- PhD] [extra 2-3 years option MD or PhD] dents who already have one previous year of postgraduate experience.' Interestingly, a re- I cent development has been the introduction of Attending physician d Consultant in A&E four year residency programmes." 12 Initially (31+ years) (32+ years) treated with a certain degree of circumspec- Formal examinations tion, these have gained acceptance, but cur- a Medical College Admission Test (MCAT) and college grades secure entry to medical school rently only comprise 10% of programmes.2" b American Board of Medical Examiners parts 1 and 2 allows progession as a United Kingdom specialist registrar training http://emj.bmj.com/ doctor into residency follows general professional training and lasts c American Board of Medical Examiners part 3 secures a permanent licence (MD) five years. The protracted training period in the d American Board of Emergency Medicine (ABEM) exams parts 1 and 2 (written and oral exams respectively) secures Board certication (taken after training) United Kingdom has been partly addressed by e "A levels" or Scottish Highers provide entry into medical school changes implemented in the Calman report.3 f Undergraduate exams to become a doctor (MD ChB) The period of general professional training in g Postgraduate college exam parts 1 and 2 (FRCS, MRCP or FRCA) the United Kingdom has no equivalent in the h Specialist A&E exam to become a fellow of the faculty (taken during training)

USA. Its opponents argue that it uses time on September 29, 2021 by guest. Protected copyright. which would be better spent in the A&E Figure I Typical career pathways in emergency medicine. department and that it is an unnecessary extension of an already long training, teaching specialties. There are no formal examination junior doctors skills which never requirements, other than those at medical they may use. school. Proponents argue that by encouraging junior doctors to experience several hospital it In the United Kingdom, entry to specialist jobs allows them to make a more informed career training can only occur after house jobs and a period of general professional in which choice at a more mature age. Interestingly, training physicians in the USA enter specialist training a postgraduate qualification in either medicine at approximately the same age as those in the (MRCP), surgery (AFRCS/MRCS), or anaes- thetics (FRCA) has been obtained. In addition, United Kingdom (fig 1). Furthermore, evidence suggests that the vast majority of Ameri- it is virtually to a impossible become specialist can residency trained A&E registrar without at least six months' attending physicians experience in the the remain in the specialty and are happy with specialty: appointing their career choice.6 14 The committee needs to be convinced about the complaint that applicant's aptitude and commitment. Such three years' training yields insufficient clinical experience is not as in the thinking does not feature heavily within the widespread. Indeed, United Kingdom, the most commonly cited American system, where a small attrition rate is complaints relate to a lack of training in accepted.2 6 administration and management."" To a certain extent, transatlantic differences Supply and demand for specialist in the length of training reflect different training philosophies. Emergency medicine trainees in Emergency medicine is expanding rapidly on the USA are being trained to help provide an both sides of the Atlantic, with the intention of "attending based" service, whereas in the Training in emergency medicine 177

Table 1 American and United Kingdom training requirements summarised J Accid Emerg Med: first published as 10.1136/emj.15.3.175 on 1 May 1998. Downloaded from US resuiency UK registrar training Entry requirement Graduation from medical school At least 3 years postgraduate training, plus FRCS, MRCP or FRCA Length of training 3 or 4 Years 5 Years Number of hospitals involved in training Usually at least two hospitals Always at least two hospitals, usually more Time in emergency department At least 50% of residency (ie, 18-24 months) Not specified, but in practice, at least 3 years Paediatric requirement Equivalent of 4 months paediatrics 3 Months paediatrics Other out of service requirements 2 Months of critical care rotations 3 Months of each of the following, if not covered in initial training: paediatrics, anaesthesia and intensive care, medicine and coronary care, general/plastic/neurosurgery, trauma and orthopaedics Hours of work Maximum 60 hours a week in the emergency Maximum 56 "full shift" hours a week in the emergency department department Supervision Available immediately at any time Variably available: usually not immediately available at night Teaching At least 5 hours of formal teaching a week No requirement Logbook Personal record required, but no specified format Logbook with standard format Assessment At least every six months Annual assessment Exams during training ABME part 3, plus yearly "in-service" exams Specialist exam in A&E (FFAEM) Research Understanding of research methodology and Involvement in several projects expected, but not specified statistics

United Kingdom the only realistic current aim in acknowledgement of the benefits of allowing is for a "consultant led" service. Extra length of trainees to experience varied training environ- United Kingdom training may therefore be ments. justified on the basis that all consultants are Each residency programme has a minimum required to supervise and teach junior doctors intake of six residents, such that even the in the same way as senior faculty members of a smallest programme will be training at least 18 teaching programme in the USA. Indeed, in residents at any one time.20 In the United some respects, the United Kingdom senior Kingdom, few programmes have more than six registrar functions similarly to a newly ap- registrars based around even the larger teach- pointed attending physician in America. ing hospitals.2' This has considerable logistic The cynic might argue that training struc- implications for training. ture is largely financially driven. In the United Kingdom, prolonged training allows more Comparison ofday to day work patients to be seen by junior doctors, whose The concept of shift work in emergency medi- rate of pay is significantly inferior to that of cine transcends international boundaries. consultants. The American system demands Regulations in the USA and United Kingdom that every patient presenting to the emergency limit the length of shifts and the number of department be seen at some stage by an hours worked per week.2'-23 The basic work of attending physician. As a result, there are pres- American residents and United reg- Kingdom http://emj.bmj.com/ sures for training to be as efficient and rapid as istrars is to see and treat patients. American possible. residents are closely supervised, such that every patient is additionally seen, or at least Structure oftraining programmes discussed with, an attending physician. Indeed, The core content or curriculum for training in the Health Care Finance Association has the USA is similar to that in the United recently mandated that all attending physicians Kingdom.'7 '` Both systems recognise the need must see and write or dictate a note on every for out-of-service training in other depart- patient seen by a resident in order to be reim- on September 29, 2021 by guest. Protected copyright. ments (table 1). '20 Formal American require- bursed. The 24 hour presence of attending ments relate to paediatrics and critical care physicians within the emergency department (including coronary care and paediatric, surgi- provides residents with an enormous amount cal, and medical intensive care). Additionally, of informal clinical teaching. Although United all programmes rotate through other key Kingdom registrar training is also based specialties and offer elective time in areas of around informal teaching, few A&E depart- personal interest. There is considerable varia- ments have sufficient consultants to allow their tion between American training programmes presence outside normal working hours. Op- in terms of the exact details of what is on offer. portunities for in-house teaching are therefore Interestingly, involvement in prehospital care more limited, despite the longer training and interhospital patient transfers receives period. United Kingdom A&E training would more emphasis in the USA: most residencies be enhanced by the introduction of formalised, require residents to spend time in ambulances regular, close supervision of registrars while and/or helicopters. Perhaps the addition of a they assess and treat patients, along similar mandatory prehospital care attachment, in- lines to those adopted in the USA. This super- cluding a short period spent with the local vision would involve the consultant being ambulance service, would usefully broaden present to observe the registrar while assessing United Kingdom training. and treating patients. Although the result Training in both systems is based within the would be an increase in the teaching workload emergency department. As the trainee of the supervising consultant, there would be progresses, a greater proportion of time is an enormous benefit to the registrar. Also, it spent there. The vast majority of training pro- would add a regular check on the clinical skills grammes in the USA and United Kingdom of the registrar-such a check is arguably rotate through more than one hospital. This is absent at the moment. 178 Wyatt, Weber

Despite the fact that there is only a limited emergency medicine requires each residency amount of data currently available, extrapola- programme to provide at least five hours of J Accid Emerg Med: first published as 10.1136/emj.15.3.175 on 1 May 1998. Downloaded from tions suggest that junior doctors in the USA classroom teaching a week.20 It further requires see approximately 4500 emergency patients attendance to be documented and that rotas during their training, whereas those in the ("schedules") and other commitments be United Kingdom see approximately 12 000 adjusted to allow all residents to attend at least patients.* 20214d Similar discrepancies appear to 70% of the teaching.20 Residents are encour- exist between the two systems as far as the aged to provide part of this teaching for each number of practical procedures performed other, under close guidance from attending during training is concerned.24 2, However, physicians. The teaching may comprise lec- although both training programmes list proce- tures, seminars, audit meetings, journal re- dures considered essential for training (see views, and research presentations. below), the number required of each has In the United Kingdom, there are guidelines neither been defined nor agreed. The situation and recommendations for the education of is further complicated in the United Kingdom senior house officers, but there is no specific by the fact that many procedures are per- requirement for formal teaching of specialist formed unsupervised (for example, at times registrars.3' 32 Such a requirement would be a when no consultant is immediately available). valuable addition. Logistical difficulties may Argument continues as to whether it is better make implementation of regular classroom training to see and treat a small number of teaching difficult, but without it, the definition patients supervised by a consultant, or a large of the word "training" is perhaps stretched number unsupervised. Close supervision may beyond that which is credible! The problem of enable improvement of clinical skills, yet being only having a small number of trainers and left unsupervised may help to develop inde- registrars in one programme could be ad- pendent thinking. An obvious compromise dressed by collaboration between hospitals within the United Kingdom training system within a region to enable a larger number of would be to introduce an element of formal- registrars to be gathered together for a formal ised regular consultant supervision, as sug- teaching day once or twice a month. These gested above. meetings would be the responsibility of the The role of the United Kingdom registrar is chairman of the regional specialist training somewhat different from that of the American committee. resident. The former has far greater autonomy, Despite a lack of formal teaching, United in terms of being able to treat and discharge Kingdom training programmes allow registrars patients. In addition to receiving training, the a half day per week for private study or United Kingdom registrar is simultaneously research. Both the American and United King- expected to spend much time acting as a dom systems encourage attendance at regional trainer, supervising more junior doctors.24 and national meetings to present research.

Similarly, completion of relevant courses (such http://emj.bmj.com/ Salary and moonlighting as ATLS, ACLS, APLS, and PALS) is usually American residency pay is remarkably similar either expected or strongly encouraged. to that ofUnited Kingdom junior doctors, with a typical annual salary of around £25 000. Administration and management However, the American University system Administration is a formal curriculum require- results in most doctors beginning residency in the USA and the United with a loan of around C70 000, as opposed to ment both Kingdom. However, evidence suggests that on September 29, 2021 by guest. Protected copyright. perhaps £10 000 among United Kingdom management training is a subject which is not graduates. As a result, having obtained a full particularly well covered. 14-6 In the United licence, American residents are tempted to Kingdom, the importance of management earn extra money by undertaking locum work. issues in training has been recognised such that This work tends to be readily available and is a specific part of the specialist examination is extremely lucrative, a typical rate of pay being devoted to testing knowledge and skills in this £50 per hour. The work is, however, usually area.33 Similarly, the American Board of Emer- completely unsupervised. More importantly, it gency Medicine examinations include ques- is very tiring, adding to an already heavy work- and load. There has been much recent concern that tions relating to administration manage- such "moonlighting" significantly detracts ment. from the educational aspect of residency and that it abuses financially vulnerable young Research and training in academic doctors.26 30 United Kingdom junior doctors in emergency medicine A&E are, in comparison, fortunate enough to It is expected that both the American resident be relatively protected from the pressures of and United Kingdom registrar will gain an moonlighting. This is a result of constraints understanding of research methodology and relating to the total number of hours worked statistics during training. The principal objec- and to a generally lesser degree of debt at the tive of this is to produce emergency physicians time of becoming a doctor. capable of evaluating research published in peer reviewed journals. In the United King- Formal teaching and study leave dom there is an implied expectation of trainee Formal classroom teaching for residents is a involvement in research. This is less true in the key feature of the American training pro- USA, owing to time constraints in a shorter gramme. The residency review committee in training programme and acknowledgement of Training in emergency medicine 179

the reality that most emergency physicians will of the training period, the specialist examin- not pursue research after completing training. ation in A&E may be taken to gain fellowship J Accid Emerg Med: first published as 10.1136/emj.15.3.175 on 1 May 1998. Downloaded from While academic emergency medicine has of the Faculty of Accident and Emergency taken great strides forward on both sides of the Medicine (FFAEM).3 This examination fo- Atlantic, training for it is relatively poorly cuses more on understanding than on knowl- developed. Trainees wishing to pursue an aca- edge: testing understanding of management demic career represent only a small minority in issues and research methodology in addition to both systems. Although there are a few specific assessing clinical competence (using objective "lecturer" or "tutor" posts in the USA, most structured clinical examination). Finally, on would-be academics are advised to target their successful completion of five years of higher applications to try to train in an institution specialist training, a certificate of completion with a recognised academic record. In the of specialist training in A&E is awarded. USA, publishing more than a handful ofpapers Joint accreditation in emergency medicine in peer reviewed journals during residency is and paediatrics was previously possible in the likely to prove difficult, but following residency United Kingdom after extra training, but the with a fellowship will provide better opportuni- situation now appears somewhat confused as a ties (see below). In the United Kingdom, the result of the introduction of recent changes. In small proportion of trainees interested in the USA, it is possible to obtain joint Board research may find time to publish 50 or more certification by combining paediatric emer- articles. Research is encouraged by one year of gency medicine or internal medicine with full time research (for example, while obtaining emergency medicine in a special five year resi- an MD or PhD), counting towards accredita- dency. tion (see below). During each training programme, meetings between trainer and trainee to discuss progress Examinations and assessment are a regular feature. Both American and Medical examinations differ greatly between United Kingdom systems require trainees to the USA and the United Kingdom. In the keep a logbook of practical procedures they USA, successful passage through the first two have performed. In the United Kingdom, a parts of the examination of the American standardised logbook has been produced by Board of Medical Examiners at medical school the Faculty ofA&E Medicine and is used in the enables graduation and practice during resi- faculty examination.33 36 Although arguments dency as a physician with a "education about how many times any particular proce- limited" licence. The third (final) part of this dure should be performed in training are diffi- examination is taken by all residents in all spe- cult to settle, a standardised logbook might be cialties during the first year of residency, after usefully introduced into residency pro- which application can be made for a perma- grammes. nent licence. The training emergency physician

is unable to take specialist examinations until Fellowships http://emj.bmj.com/ after residency. The two part American Board Exclusive to the American system, after of Emergency Medicine examination is usually residency attending physicians can apply to taken in the first year as an attending physician take up a "fellowship" for one to three years. and has pass rates of 60% and 74% These are mainly university posts, enabling respectively.2 Success results in Board certifica- further training within a subspecialty, includ- tion in emergency medicine (accreditation). ing research (often aimed towards a PhD or a Additionally, all emergency medicine resi- Masters degree in Public Health), prehospital dents across the country are required to sit the care, administration, paediatrics, toxicology, on September 29, 2021 by guest. Protected copyright. same multiple choice question paper ("In- critical care, and hyperbaric medicine. Such a service" examination) based upon the curricu- post provides a foothold within the university lum annually. While this is not a formal system and is suited to those contemplating an examination, residents and trainers receive academic career. The United Kingdom system individual scores and a national rank. This has sufficient length and flexibility for equiva- provides an incentive for regular study and lent subspecialty training and research to be allows residents and trainers to assess knowl- incorporated within it. edge base, enabling improvement in identified areas of weakness. The spread of results for Recommendations for future United each programme also reflects the teaching pro- Kingdom training vided. Many of the transatlantic differences in train- In the United Kingdom, examinations in ing for emergency medicine reflect different A&E continue to evolve. Having entered systems and more importantly, the different specialist training, there is no regular test of roles of the doctors that each aims to create. knowledge. It is generally agreed, however, that There are, nevertheless, positive attributes of there is a need for some form of regular each training programme which may be assessment.33-35 An equivalent in-service test usefully applied to the other. As the specialty of after one or two years would certainly encour- emergency medicine develops, those responsi- age directed reading, possibly lacking at ble for training face an exciting challenge. If present. It would provide trainers with an expansion continues apace in the United King- objective measure of progress at annual assess- dom as expected, it will be appropriate to con- ment and help to identify those training sider implementing changes. These may in- programmes in need of re-evaluation by the clude many of the features of the American specialist advisory committee. Towards the end training programmes currently rejected as 180 Wyatt, Weber

being logistically impossible. To summarise, 16 Johnson G, Brown R, Howell M. Higher specialist training

in accident and emergency medicine-past, present and J Accid Emerg Med: first published as 10.1136/emj.15.3.175 on 1 May 1998. Downloaded from introduction of the following is recommended future. J Accid Emerg Med 1997; 14:104-6. for United Kingdom training: 17 American College of Emergency Physicians, American Board of Emergency Medicine, Society for Academic 1 A mandatory prehospital care attachment. Emergency Medicine. Core content for Emergency Medi- cine. Ann Emerg Med 1991;20:920-34. 2 Formalised regional weekly teaching pro- 18 Faculty of Accident and Emergency Medicine and Special- grammes. ist Advisory Committee in Accident and Emergency Medi- consultant cine. Curriculum for higher specialist training in Accident and 3 Formalised regular "one to one" Emergency Medicine. London: Faculty of Accident and supervision of A&E trainees while they Emergency Medicine, 1995. assess and treat patients. 19 Board of the Faculty ofAccident and Emergency Medicine. Guidelines for specialist training in accident and emergency 4 "In-service" training examinations for all medicine. London: Faculty of Accident and Emergency A&E trainees. Medicine, 1996. 20 Residency Review Committee in Emergency Medicine. Pro- We wish to thank the following for sharing their not inconsider- gram requirements for residency education in emergency able experience: Dr M Allswede, Professor W Barsan, Dr C medicine. American Council for Graduate Medical Educa- Chudnofsky, Dr J Cisek, Dr S Dronen, Dr K Little, Dr R Maio, tion, 1996. and Mr M Rady. 21 British Association for Accident and Emergency Medicine. JPW received a grant from the Ethicon Foundation Fund of The way ahead: accident and emergency services 2001. the Royal College of Surgeons ofEdinburgh to study training in London: British Association for Accident and Emergency Michigan. JEW received funding from the William Beaumont Medicine, 1992. Hospital Foundation to study training in Scotland. 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