Research

Clinical Rotations

Residency Program in Emergency Medicine Didactic and Clinical Curricula

The goals of our EM residency program are to:

  1. Produce physicians eligible for board certification according to the pathways outlined by ABEM
  2. Prepare physicians for a long, rewarding, productive, satisfying, and fulfilling career in EM

Upon successful completion of the residency training program, our graduates are able to:

  1. Recognize, resuscitate, stabilize, evaluate, and care for the full spectrum of patients who present to the ED
  2. Apply critical thinking to determine the priorities for evaluation and treatment of multiple ED patients with different complaints and needs
  3. Arrange appropriate follow-up or referral as required
  4. Manage the out-of-hospital care of the acutely ill or injured patient
  5. Participate in the administration of the EMS system providing out-of-hospital care
  6. Provide appropriate patient education directed toward the prevention of illness or injury
  7. Engage in the administration of EM
  8. Teach EM
  9. Understand and evaluate research methodologies and their applications
  10. Understand and apply the principles and practice of continuous quality improvement
  11. Manage resource utilization effectively
  12. Utilize information resources effectively and apply evidence-based medicine to update their clinical practice
  13. Communicate effectively with patients, families, and health-care professionals
  14. Utilize resources to address domestic violence and other public health issues, including violence prevention
  15. Demonstrate the fundamental qualities of professionalism
  16. Demonstrate how optimal patient care is provided in the context of a larger health-care delivery system by effectively using system resources to support the care of patients

The clinical program is structured over 36-months and is detailed in the residency program block diagram. The clinical program is in compliance with all institutional, ACGME, and New York State duty-hour regulations. Successful completion of all requirements and objectives of the clinical program qualifies residents for the certification examination series provided by the American Board of Emergency Medicine (ABEM). The clinical curriculum is described below:

EM-1 Clinical Program Description

EM-1 residents gain exposure to a wide variety of disciplines during their initial year of training.

This exposure is integral to the development of a sound, comprehensive foundation of general medical knowledge upon which to build a successful academic and clinical career in EM.

The first four-week block consists of an introduction to EM and to the ED at NSUH. Residents receive introductory lectures on emergent medical, nontraumatic surgical, traumatic, obstetric, gynecologic, ophthalmologic, and orthopedic conditions, and participate in courses leading to certification in BLS, ACLS, ATLS, and PALS.

Residents are provided with internet-based, self-educational tutorials for research-related and other mandatory orientation topics (introduction to informed consent, research HIPAA, human subjects protection, infection control certification, respirator testing, HIPAA compliance training, documentation guidelines, faculty practice compliance, and HCCS education) as well as preliminary procedural sedation certification.

During the remainder of the EM-1 year, residents receive an overview of inpatient medical and surgical services by completing off-service rotations in the MICU, the CCU, the SICU, and in OB-GYN inpatient care areas (labor and delivery suites) and by spending several blocks on rotation in the ED.

In addition, two blocks (eight weeks) are devoted specifically to shifts in the Pediatric ED.

Two weeks are dedicated to introducing the residents to the applications of ultrasound for ED patients.Two weeks are dedicated to introducing residents to principles and practice of Emergency Medicine sports medicine.

A rotation in anesthesiology exposes the EM-1 resident to the principles of anesthetic pharmacology, modified rapid sequence induction, and techniques of deep procedural sedation, in addition to the experience he/she acquires with basic and advanced airway management.

Two weeks of rotation in Plastic and Reconstructive Surgery and Hand Surgery complete the first year clinical program.

Each EM resident is provided with four weeks of paid vacation annually.

Responsibilities

EM-1 residents are expected to perform the history and physical examination related to the presenting chief complaint of the patient.

EM-1 residents are expected to formulate an appropriate differential diagnosis and present their clinical findings to the senior EM resident and/or the attending physician faculty member for discussion and formulation of the diagnostic evaluation and treatment plan. EM-1 residents are expected to develop a diagnostic plan under the direction of the ED attending physician including appropriate radiological, laboratory, and ancillary testing. EM-1 residents begin to learn the utility of the differential diagnostic and therapeutic modalities for specific disease processes.

Residents also learn to recognize life/limb-threatening conditions and to initiate stabilization under the direct and immediate supervision of ED attending physician faculty member and the senior EM resident. The EM-1 resident is a member of the team for both trauma and medical resuscitations.

EM-1 residents begin to develop expertise in patient care and medical decision-making, including when to admit, discharge, request consults, and schedule follow-up visits, and they begin to develop proficiency with medical documentation.

EM-1 residents develop knowledge of the various disease states they encounter, including the classical presentations, the underlying relevant pathophysiology, and the pertinent differential diagnoses related to the presenting chief complaints.

The fund of medical knowledge is expanded through core readings, didactic sessions, and readings related to specific conditions encountered in the ED, as well as through discussion with both senior EM residents and attending physician faculty members during clinical shifts.

EM-1 residents participate in the clinical and didactic instruction of paramedic students, allied-health professional students, and allopathic and osteopathic medical students concurrently on rotation in the ED.

Supervision

EM-1 residents are closely supervised by senior residents and attending faculty on all cases.

They are assigned patients to evaluate by the senior EM resident and/or attending physician. Residents perform the initial evaluations, present their findings, and formulate the diagnostic and treatment plans for every patient they encounter.

Each case is reviewed and discussed with the attending physician or senior EM resident after the initial history and physical is completed. EM-1 residents then complete the necessary patient care and management tasks, including the following: performing required procedures, ordering and interpreting pertinent laboratory studies and radiographic studies, obtaining consultations (if necessary), arranging for patient admission, and (if necessary) completing all discharge planning activities.

All decisions made by EM-1 residents are reviewed by the supervising senior EM resident and/or the attending physician prior to their implementation. All procedures are supervised at the bedside by the attending physician faculty members.

Supervision is performed to enhance independent decision-making and responsibility of the EM-1 resident. All patients are seen and examined independently by the ED attending physician.

EM-2 Clinical Program Description

EM-2 residents experience a progressive increase in responsibility and autonomy.

Residents spend several months in the ED, with additional time dedicated to the Pediatric ED at Cohen Children’s Medical Center (CCMC).

In addition, EM-2 residents receive more critical care experience (as the “senior resident”) in the SICU.

Trauma experience is acquired through a rotation in EM/Trauma at the R. Adams Cowley Shock Trauma Center (part of the University of Maryland Medical Center) in Baltimore, Maryland.

Additional pediatric anesthesiology experience is gained by rotating through the Department of Anesthesiology at SCH. During the afternoon portions of the pediatric anesthesiology rotation, EM residents work short shifts in the Pediatric ED at CCMC. These brief shifts (6 hours) serve to augment their pediatric experiences and provide additional opportunities for EM residents to apply knowledge learned in pediatric anesthesiology to patients encountered in the Pediatric ED.

One month of medical toxicology is completed by rotating with other tri-state area EM residents at the NYCPCC.

Residents are exposed to EMS during a rotation with NYC’s EMS system (FDNY).

Residents complete a two-week rotation learning advanced ultrasound techniques.

EM-2 residents are expected to more actively participate in all aspects of the didactic curriculum (i.e. deliver evidence-based, literature-supported, CME-quality PowerPoint core content presentations), and to generate ideas and concrete proposals for completion of their research and scholarly activity residency requirement.

Responsibilities

EM-2 residents are expected to take a more active clinical role in the ED. Residents at this level possess more expertise with history acquisition, patient assessment, differential diagnosis formulation, and management and treatment plan generation.EM-2 residents routinely recognize classical presentations of disease processes and begin to develop a familiarity with "atypical" presentations.

The EM resident, at this level, presents all cases to the senior EM resident and/or the ED attending physician. Under the immediate and direct supervision of the senior EM resident and/or the ED attending physician, the EM-2 resident formulates and presents treatment plans and initiates prompt therapeutic intervention.

The EM resident directs medical resuscitations, participates in trauma resuscitations, and acquires mastery with emergent procedures.EM-2 residents formulate precise diagnostic plans prior to presenting cases to the ED attending physician.

EM-2 residents demonstrate expertise in discharge planning, admission procedures, patient transfer acceptance and execution, and emergent and elective consultation acquisition. Appropriate and timely follow-up visits are provided for all patients.

EM-2 residents develop in-depth knowledge of the various disease states and demonstrate knowledge of the advances in EM as reported in the scientific literature. Knowledge of all commonly used therapeutics is thorough at this level. EM-2 residents participate in the clinical and didactic instruction of paramedic students, allied-health professional students, allopathic and osteopathic medical students, and other fellow EM resident physician colleagues.

Supervision

EM-2 residents take a more active clinical role in the ED and have greater responsibility, autonomy, and authority when evaluating patients. They are expected to see an average of one to two patients per hour and manage several patients simultaneously.

EM-2 residents perform the initial evaluations, institute their diagnostic and treatment plans, and bring their patients’ management to conclusion more independently. The ED attending physician is always available for consultation whenever needed.

Procedures are supervised commensurate with the individual EM resident's ability and familiarity with the procedure; those procedures for which the EM resident has been credentialed may be performed by the EM resident with less direct supervision from the ED attending physician (all procedures, however, always require direct supervision during the “key portions” of the procedure).

EM-2 residents may direct resuscitations under close supervision of the senior EM resident and/or the attending physician faculty member in the second half of the EM-2 year. EM-2 residents are given opportunities, as available, to pilot the senior EM resident role during the final month of their second year. All patients are seen and examined independently by the ED attending physician faculty member.

EM-3 Clinical Program Description

EM-3 residents (senior EM residents) spend most of the third year in the ED at NSUH.

They are responsible for all clinical, educational, and administrative functions of the department, under the appropriate supervision of ED attending physicians.

Two blocks are also dedicated to systems-based practice (ED administration), also a rotation during which the EM-3 resident further develops an appreciation for the administrative and medicolegal issues encountered in EM. In addition, residents spend part of this time caring for patients in the Clinical Decision Unit (CDU or Observation Area) learning the principles of Observation Medicine, which is becoming increasingly more common as a feature of practice, and thus important in EM resident’s education.

One block is reserved for resident-chosen Selective Rotations. These may include, for example, rotations in International EM/Global Health, Musculoskeletal Radiology, Primary Care Sports Medicine, Advanced Plastic and Reconstructive Surgery/Hand Surgery, Opthalmology, Dental Medicine, Trauma Anesthesiology, and EM/Trauma.

The remaining block is designated as elective time, to be used in an educational pursuit at the resident’s discretion and with the permission and approval of the PD.

Responsibilities

The senior EM resident is given increased responsibility with regard to all diagnostic, therapeutic, and management decisions, with the goal of facilitating EM resident development into an attending physician capable of independent practice.

Senior EM residents have a well-developed expertise in recognizing classical and atypical presentations of the majority of disease processes seen in the ED.Senior EM residents perform appropriate and timely evaluations of all patients seen in their clinical area.

Senior EM residents develop and formulate appropriate diagnostic and therapeutic treatment plans prior to presentation to attending physician faculty members.Senior EM residents initiate prompt therapeutic intervention under the supervision of the ED faculty as needed.Senior EM residents demonstrate expertise in discharge planning, admission procedures, patient transfer acceptance and execution, and emergent and elective consultation acquisition. Appropriate and timely serial evaluations are performed when clinically indicated.

Although EM residents at this level function more autonomously than junior level residents, there is access to an attending physician faculty member at all times for consultation. All cases are presented to the attending physician faculty member by the time of final disposition. All patients are independently evaluated by the attending physician faculty member.

The senior EM resident is responsible for all patient care activities in his/her designated patient care area of the ED, under the supervision of an ED attending physician. In addition to his/her own patient care responsibilities, the senior EM resident’s responsibilities include the supervision of ED patient triage and throughput (flow), resolution of administrative problems as they relate to patient care, review of cases with junior EM residents, students, and other health care personnel, and teaching of clinical procedures.

The senior EM resident directs all medical, surgical, and trauma resuscitations in his/her clinical area in the ED, under the direct supervision of the ED attending physician faculty member. In addition, the senior EM resident provides medical control oversight and options for the NS-LIJHS EMS, and performs (when necessary) all laboratory, radiographic, and ECG reviews, follow-ups, and callbacks, under the supervision of the ED attending physician.

Senior EM residents are expected to:

  • Provide at least 24-hours of senior EM resident coverage (in adult patient care areas)
  • Provide additional senior EM resident coverage in other patient care areas (i.e. Advanced Patient Care ("Rapid Access") Area, Pediatric ED, or "Midway" Area) on a periodic basis
  • Adhere to a senior EM resident sick call schedule to ensure coverage at all times
  • Distribute junior EM residents to the patient care areas which would maximize opportunities for junior/senior EM resident interaction

The key principle regarding the roles and responsibilities of senior EM residents is that their roles and responsibilities should duplicate as closely as possible that of the ED attending physician. The ED attending physicians allow the senior EM resident as much of an opportunity as possible to act as the physician-in-charge of the area.

Senior EM residents are expected to have primary care responsibility for a significant number of patients while at the same time performing their supervisory and other duties. Regarding patient flow, the senior EM resident should (as much as possible) screen all patients arriving to the acute area by ambulance. Senior EM residents should work closely with the ED attending physician by presenting and reporting (periodically) on the progress of all patients in their patient care areas.

Medical records should be completed by senior EM residents in order to meet or exceed all department, performance improvement, medicolegal, and Federal (e.g. HCFA, HIPAA) documentation guidelines and regulations (in preparation for independent practice after graduation).

Supervision

Senior EM residents independently manage their patients with a minimum of initial input from the supervising faculty. All patient care assessments, interventions, management and disposition decisions, and all medical control decisions must be made in compliance with the NS-LIJHS Policy and Procedure Regarding the Supervision of Patient Care Provided by Graduate Staff Officers.

Senior EM residents are expected to see two to three patients per hour and manage multiple patients simultaneously, while supervising junior EM residents, allopathic and osteopathic medical students, and other allied health professions and students.

Although senior EM residents function more autonomously than junior level EM residents, there is access to an attending physician faculty member at all times for consultation. All cases are presented to the attending physician faculty member by the time of final disposition. All patients are independently evaluated by the attending physician faculty member.