Past and future of emergency medicine education and training

Science fiction movie fans will already be familiar with one possible future for emergency medicine education and training. In the 1999 film The Matrix (Warner Bros.® Entertainment) Keanu Reeves's character Neo simply connects to a computer via a port in the back of his head and receives a ‘direct download’ of knowledge and skills ranging from martial arts and bullet dodging to languages (enabling him to save the world, obviously). The experience appears briefly painful but incredibly efficient. But is this really the right way to acquire the knowledge and skills required for a 21st century emergency physician? Can an efficient ‘direct download’ ever capture the science and art of our practice? Approaches to undergraduate medical education in the USA were shaped by the Flexner reforms in the early 20th century and were largely responsible for the current structure of most Western medical schools, with preclinical learning phases followed by apprenticeship based clinical rotations. ‘Emergency medicine’ does not appear as a distinct curricular area within these medical schools, which were generally structured according to the pathological basis of disease. It was the establishment of emergency medicine as a specialty – with dedicated EDs and staff – that required the development of specific training programmes. This occurred in the early 1970s in the USA and similar developments occurred in Australasia, Canada and the UK over the next 10–20 years. Prior to this, staff in Australasian EDs had generally trained in other specialties – surgery, general practice, or medicine – or were pre-vocational doctors. The story of the ACEM training programme for emergency medicine specialists is impressive. A curriculum and training programme was developed with a similar structure, duration and examination system to the other specialist medical colleges. The first Primary Examination (testing the basic sciences of anatomy, pathology, physiology and pharmacology) was first conducted in 1984. The first Fellowship Examination, a six-part clinical exit examination, was held in 1986 with eight successful candidates.4 Since the establishment of the college training programme, more than 1000 Fellows have graduated. There has been maturation of training processes, curriculum and assessment, and development of robust systems of accreditation of EDs for training. The current Curriculum Revision Project5 promises a significant renewal of curricular objectives and of training and assessment processes. The scope of clinical knowledge and skills required for physicians working in emergency medicine is broad and overlaps with most other specialty areas. Following the general trend in medical education, emergency medicine training now also explicitly includes ‘professional’ domains of learning, including communication, leadership, ethics, teamwork, management and system-based practice. These domains remain underrepresented in teaching activities and in assessment, despite their critical importance in contemporary practice. So what does a contemporary emergency medicine training program in 2013 look like? How close are we to a ‘direct download'? Accredited EDs also offer structured teaching to support workplace experience. This includes large and small group teaching, journal clubs, procedural skills training and simulation, online learning and a variety of other innovative formats. Most trainees also augment this learning with external resources, including Social Media, FOAM7 and dedicated workshops for skills, such as ultrasound. Assessment drives learning in every educational programme, and the emergency trainees' focus is often on passing exams. Independent specialist examinations were an early signal of emergency medicine's credibility as a specialty in Australasia. The adoption of rigorous psychometric analysis of examinations and of workplace based assessment in emergency medicine are typical of the broader evolution in assessment in medical education. But are these advances in educational approach enough? Do our ED patients have better outcomes and experiences than they did prior to 1986 when our first Fellows by examination graduated? Alternatively – are our techniques also wrong? Have we ‘over-codified’ our emergency medicine science and art? Does the competency approach fail to include the tacit elements of our expertise? Those science fiction film fans will also be familiar with this alternative future for emergency medicine education and training. In the 1980 Star Wars sequel The Empire Strikes Back (Lucasfilm® Ltd), we follow Luke Skywalker's struggle as a trainee Jedi Knight. There are no books, no podcasts, no lectures and no assignments – simply a ‘clinical immersion’ on the planet of Dagobah, under the apprenticeship of Yoda, a Jedi Master. The training and the Master are tough. Yoda has high (but clear) expectations. He is prepared to support but not spoon feed and makes it clear that life and death will be outcomes related to Luke's competence… . ‘No. Try not. Do, do. Or do not. There is no try’.9 The future challenges for which this education is preparing him for are not clear – there will not be easy recipes, but there will be best practice, core principles and a need for flexibility and adaptability. Sometimes Luke fails his challenges, sometimes he succeeds. Perhaps most importantly, when Luke leaves planet Dagobah after his training, he is under no delusion that he is finished his education… . None declared.

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