The Journal of Emergency Medicine, Vol. 48, No. 6, pp.

732743, 2015
Copyright 2015 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2014.12.063

Education
IMPLEMENTING A THIRD-YEAR EMERGENCY MEDICINE MEDICAL
STUDENT CURRICULUM
Matthew C. Tews, DO, MS,* Collette Marie Ditz Wyte, MD, Marion Coltman, MD, Kathy Hiller, MD,
Julianna Jung, MD, Leslie C. Oyama, MD,k Karen Jubanyik, MD,{ Sorabh Khandelwal, MD,#
William Goldenberg, MD,** David A. Wald, DO, Leslie S. Zun, MD, Shreni Zinzuwadia, MD,
Kiran Pandit, MD, MPH,kk Charlene An, MD, MSC,{{ and Douglas S. Ander, MD##
*Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, Department of Emergency Medicine, Oakland
University, William Beaumont School of Medicine, Royal Oak, Michigan, Department of Emergency Medicine, University of Arizona Health
Network, Tucson, Arizona, Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, kUCSD
Emergency Medicine, University of California, San Diego, San Diego, California, {Department of Emergency Medicine, Yale-New Haven
Hospital, New Haven, Connecticut, #Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, Ohio,
**Department of Emergency Medicine, Naval Medical Center, San Diego, California, Department of Emergency Medicine, Temple University
School of Medicine, Philadelphia, Pennsylvania, Department of Emergency Medicine, Mount Sinai Hospital, Chicago Medical School,
Chicago, Illinois, Department of Emergency Medicine, New Jersey Medical School-University Hospital, Newark, New Jersey, kkDepartment
of Emergency Medicine, Columbia University, New York, New York, {{Department of Emergency Medicine, SUNY Downstate Medical
Center, Brooklyn, New York, and ##Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
Reprint Address: Matthew C. Tews, DO, MS, Department of Emergency Medicine, Medical College of Wisconsin, 9200 W Wisconsin Avenue,
Milwaukee, WI 53226

, AbstractBackground: Emergency medicine (EM) is

commonly introduced in the fourth year of medical school
because of a perceived need to have more experienced students in the complex and dynamic environment of the
emergency department. However, there is no evidence supporting the optimal time or duration for an EM rotation,
and a number of institutions offer third-year rotations.
Objective: A recently published syllabus provides areas
of knowledge, skills, and attitudes that third-year EM rotation directors can use to develop curricula. This article expands on that syllabus by providing a comprehensive
curricular guide for the third-year medical student rotation with a focus on implementation. Discussion: Included
are consensus-derived learning objectives, discussion of
educational methods, considerations for implementation,
and information on feedback and evaluation as proposed
by the Clerkship Directors in Emergency Medicine
Third-Year Curriculum Work Group. External validation
results, derived from a survey of third-year rotation directors, are provided in the form of a content validity index for

each content area. Conclusions: This consensus-derived

curricular guide can be used by faculty who are developing
or revising a third-year EM medical student rotation and
provide guidance for implementing this curriculum at their
institution. 2015 Elsevier Inc.
, Keywordsthird-year; curriculum; medical student;
emergency medicine

INTRODUCTION
Emergency medicine (EM) offers medical students a variety of clinical experiences that are directly applicable to
their future careers, regardless of specialty choice (1,2).
Students completing an EM rotation encounter acutely
ill and injured patients with complaint-based presentations. They learn the evaluation and management of the

RECEIVED: 13 May 2014; FINAL SUBMISSION RECEIVED: 5 November 2014;

ACCEPTED: 22 December 2014
732

Third-Year EM Medical Student Curriculum

undifferentiated patient in addition to learning how to

handle common and life-threatening medical problems.
A fourth-year rotation has traditionally been the most
common EM experience for medical students (3). A
recent survey has shown that EM is also incorporated
into the third year at many institutions (4). When situated
in the third year, the goals of an EM rotation are fundamentally different than for more senior students. While
a fourth-year EM experience focuses on creating diagnostic and management plans for patients, the thirdyear rotation provides exposure to EM principles and
practice, teaching the approach to the undifferentiated patient and basic emergency management skills (5,6). The
literature provides a number of resources relating to the
fourth year, but there are few resources with a focus on
the third-year experience (3,612).
For all of these reasons, EM educators would benefit
from a uniform curricular approach to the education of
students in the third year. To address this need, this article
provides a comprehensive curricular guide that expands
on a previously published syllabus of content to include
consensus-derived learning objectives, discussion of
educational methods, considerations for implementation,
and information regarding feedback and evaluation (5). It
provides the rotation director with the core content and
resources needed to implement or revise a third-year rotation. External validation results, derived from a survey of
third-year rotation directors across the country, are provided in the form of a content validity index (CVI) for
each of the content areas (13). This curriculum was developed using the six-step Kern model for curriculum development and is presented in this fashion (14).
DISCUSSION
Step 1: Problem Identification and General Needs
Assessment
There is currently a significant emphasis on competencybased education, as evidenced by initiatives like the
American Council on Graduate Medical Educations
next accreditation system or Milestones and the
American Association of Medical Colleges document on
Entrustable Professional Activities (EPAs) (15,16). EPAs
are observable and measurable descriptors of what all
medical school graduates should be expected to perform
on day 1 of residency without direct supervision. Among
these, medical school graduates are expected to be able
to recognize and initially manage patients requiring
urgent or emergent care. This underscores the importance
of EM competencies as core foundational skills for all
medical students, and reinforces the role of EM in
helping medical schools meet Liaison Committee on
Medical Education (LCME) requirements (17,18).

733

Despite the recognition of emergency management as

a core competency for all physicians, medical schools
have variable integration of EM into their existing
curricula (4,12). While there is no evidence supporting
the optimal placement of EM in the medical school
curriculum, many institutions offer EM during the
fourth year of medical school because of a perceived
need to have more experienced students in the complex
and dynamic environment of the emergency department
(ED). To address this need, a fourth-year EM medical student curriculum was published and recently updated to
provide a consistent clinical experience for the senior
medical student (6).
However, a number of institutions offer third-year rotations either in place of or in addition to a fourth-year
rotation. In a recent survey of EM clerkship directors in
the United States, 28% have an elective third-year rotation and 14% have a required third-year EM experience
at their institution (4). These experiences are variable
with differences in the type and length of clinical experience, content taught, assessment methods and types of resources used (12). Due to this variability, as well as the
growing prevalence of third-year EM rotations, the Clerkship Directors in Emergency Medicine (CDEM) Third
Year Curriculum Work Group was formed in 2010 with
the goal of promoting uniformity of the third-year EM
experience and developing a curriculum that addresses
the core knowledge, skills, and attitudes essential for
third-year EM students.
Step 2: Targeted Needs Assessment
In 2011, the Work Group published a syllabus of content
for a third-year EM rotation using the National Institute
of Health model for consensus building (5). The publication was the result of a targeted needs assessment conducted by 17 EM rotation directors and experienced
educators. The group compiled a broad list of content
areas that was further refined via a series of online surveys, emphasizing the approach to the undifferentiated
patient, the ability to differentiate patient acuity, the ability to perform simple procedures, and the basic management of critical life-threatening emergencies.
The syllabus content was compiled into a MustShould-Can framework. In this model, Must indicates
essential components to be provided by all institutions,
regardless of rotation length. Should indicates highly
desirable elements, and Can indicates elements that
can be taught depending on the institutions strengths
and resources. This framework provides flexibility to
EM educators within their individual institutions,
while ensuring that critical Must elements are taught
universally in the third year. Although this curriculum is
recommended for a four-week clerkship, the Must-

734

Should-Can model allows for placement at any point during the third year, adaptation for the experienced versus the
novice student, shorter rotations, inter-specialty or longitudinal EM experiences and multi-site rotations (19,20). The
third-year syllabus was designed to be a distinct entity
from the fourth-year medical student curriculum.
After publication of the syllabus, the Work Group
drafted learning objectives for all curricular content. Using the Delphi approach, Work Group consensus was obtained for the Must objectives through a series of
online surveys. The Should and Can learning objectives were refined in the same way as the Must objectives.
Given the wide variety of potential third-year curricula
in existence, the Work Group sought input from thirdyear rotation directors external to the Work Group to
assess the content validity of the curriculum. CDEM
members were contacted via the CDEM list serve to identify third-year rotation directors willing to participate in
an online survey. Thirteen rotation directors responded
to the inquiry and each was sent an anonymous online
survey. Of the 13 respondents, 11 completed the survey,
representing a mix of student experience that include
elective, selective, and mandatory rotations ranging
from 2 to 6 weeks in length.
Step 3: Goals and Objectives
Curriculum goals for the third-year student.
1. To gain exposure to EM principles and practice.
2. To understand the signs and symptoms of the
acutely ill or injured patient.
3. To become familiar with the initial evaluation of a
broad variety of medical and surgical emergencies.
4. To develop a differential diagnosis based on lifethreatening causes of common chief complaints.
5. To develop an approach to the initial resuscitation
and management of the undifferentiated patient.
6. To begin to develop the knowledge, skills, and attitudes necessary for the practice of EM.
Learning objectives and core curriculum.Table 1 lists the
Must learning objectives derived from the Work
Groups consensus recommendations, and outlines the
core curriculum content, including potential educational
and assessment methods, with correlations to the
Accreditation Council for Graduate Medical Education
competencies, the American Board of Emergency Medicine Milestones and the Entrustable Professional Activities for graduating medical students (15,16,21). Each
content area is associated with a CVI based on the
survey responses of the external third-year rotation di-

M. C. Tews et al.

rectors. The learning objectives must be shared with

all teaching faculty and residents to ensure consistent
education and evaluation, and to meet LCME requirements for required clerkships (22). The Should
(Appendix 1) and Can (Appendix 2) objectives are
also included, but do not have an external validation
component because they represent additional content
areas that can be incorporated based on the resources
of the department or institution.
External validation of Must content and learning objectives. A CVI is a measurement of content relevance
determined by a group of individuals knowledgeable in
a content domain (13). To determine our curricular content validity, a group of 11 external third-year rotation directors reviewed the curricular content developed by our
Work Group and provided perspective on the importance
of each content area via a standardized electronic survey.
The content validity index for each content area is listed
in Table 1. The closer the CVI is to 1.0, the greater the
extent of agreement, therefore, the higher the content validity (23). The overall CVI for all items is 0.90, indicating
a high degree of validity for the curricular content. CVI
calculations for the 16 content areas ranged from 0.64
to 1.00. Nine of 16 content areas had a CVI of 1.0 indicating the highest degree of content validity. The two
areas with the lowest CVI, Basic and Advanced Life
Support Techniques and Documentation, had only
two individuals who disagreed, resulting in a value of
0.64, which still demonstrated a good degree of validity
for these areas.
Respondents to the survey were also asked if they
would agree, modify, or disagree with each specific
learning objective. Of the 41 Must learning objectives,
>90% of external respondents agreed with 27 of them as
written. There was little or no disagreement with most
remaining objectives, with the majority choosing to
modify the remaining ones. Suggestions for modifications were provided in some cases, but did not significantly
alter the content of any learning objectives. The majority
of disagreement surrounded the Documentation objectives. Respondents indicated that covering documentation
in a shorter rotation is difficult or preferably reserved for
the fourth year. Given the importance of documentation
in EM, the Work Group retained documentation of the
core chief complaints, as well as the procedural and medicolegal aspects, to provide students exposure to an important skill set that can be developed over time.
Pediatrics. 1. Pediatrics is a core rotation in the third year
of all United States (US) medical schools (22). The Council on Medical Student Education in Pediatrics has
created a national curriculum that has been adopted by
>90% of the Pediatric Clerkships in North America

Content

CVI

The Approach to the

Undifferentiated
Patient

1.00

Stabilization of the
Acutely Ill Patient

0.82

Vital Signs

1.00

Basic and Advanced

Life Support
Techniques

0.64

Revised Learning Objectives

1. Describe the approach to the
undifferentiated patient.
2. Describe a stable vs. an unstable patient, identifying clinical signs and symptoms
indicative of life-threatening
illness.k
1. Describe the clinical approach to
an unstable patient, including the
assessment and monitoring of
airway, breathing, and circulatory
status.k
2. Describe the purpose of establishing an intravenous, O2 and
monitor during initial assessment of the unstable patient.k
3. Describe the clinical approach to
a patient in each category of
shock (hypovolemic, cardiogenic, distributive, obstructive)
and list the differential diagnoses
1. Interpret abnormal vital signs
(heart rate, respiratory rate, blood
pressure, temperature, and oxygen saturation) and identify the
potential causesk
1. Describe the indications for using
basic airway maneuvers,
including head tilt, chin lift, and
jaw thrust, and demonstrate their
usek
2. Describe the indication for using
airway adjuncts, including oral
and nasopharyngeal airways, and
demonstrate their use.k
3. Discuss the indications for bagvalve-mask ventilation and
demonstrate the correct
techniquek
4. Describe the approach to a patient in cardiac arrestk
5. Define and demonstrate highquality chest compressionsk
6. Demonstrate how to perform
manual defibrillation

Educational
Methods*

Assessment
Methods

ACGME Competencies,
ABEM Milestones,
and EPA

References

L, IS, Podcast

C, G, SOE, MCQ,
Sim, OSCE

PC-1,2,3,5,6
MK
EPA-10

EMCP: Chapter 6: Undifferentiated and

Differentiated Patients
CDEM: Approach to the
Undifferentiated Patient

L, IS

C, G, OSCE, Sim,
SOE, MCQ

PC-1,2,3,4,5,6,10
MK
EPA-10

CDEM: Stabilization of the Acutely Ill

Patient; Approach to: Shock;
Approach to: Gastrointestinal
bleeding; Approach to: Trauma

L, IS

SOE, MCQ, EOS

PC-1,5,6,10
MK
EPA-10

EMCP: Chapter 11: Developing Your

Plan of Action
CDEM: Approach to the
Undifferentiated Patient

L, S, EL

C, G, Sim, MCQ

PC-1,4,5,6,10
MK
EPA-10, 12

CDEM: Basic and Advanced Life

Support
Current BLS/ACLS/PALS guidelines

735

Continued

Third-Year EM Medical Student Curriculum

Table 1. Must Third-Year Emergency Medicine Curriculum Content

Content

736

Table 1. Continued

CVI

Revised Learning Objectives

1.00

1. Perform a focused history and

physical examination for a patient
presenting with:
a. Chest pain
b. Abdominal paink
c. Shortness of breathk
d. Altered mental statusk

Chief Complaint
Differential
Diagnosis

1.00

Diagnostic Testing

1.00

Electrocardiogram
(ECG)/Rhythm
Recognition

0.82

1. List the common and lifethreatening causes of:

a. Chest pain
b. Abdominal paink
c. Shortness of breathk
d. Altered mental statusk
Laboratory studies
1. Describe the indications and uses
of common laboratory studies
(e.g., complete blood count,
basic metabolic panel, coagulation studies, liver function, lipase,
cardiac enzymes and lactate),
and what is normal vs. abnormal.
Radiographic studies
1. Describe the indications and uses
of a chest x-ray and abdominal
series radiograph.k
2. Interpret a normal chest x-ray
and abdominal series radiograph
and identify potential life threatening findings.k
Bedside testing
1. Interpret a normal 12-lead
electrocardiogram (ECG)
1. Identify ventricular fibrillation (VF)
and ventricular tachycardia (VT)
on a rhythm strip and describe
the initial treatment for the patient
without pulses.k
2. Describe the initial management
of shockable (VF and pulseless
VT) vs. nonshockable (asystole
and pulseless electrical activity)
rhythms in cardiac arrest and list
the potentially reversible causes
(the Hs and Ts).k
3. Describe the causes, ECG criteria
and management of an ST
elevation myocardial infarction
and interpret on an ECG.

Assessment
Methods

ACGME Competencies,
ABEM Milestones,
and EPA

References

L, IS, C, S,
EL, SG

C, G, OSCE, Sim,
SOE, SP, MCQ,
EOS, BE, DO

PC-2
MK
PBLI
PROF-1,2
EPA-1

L, C, E, SG, S, IS

C, Sim, SOE,
MCQ, EOS

PC-2, 3, 4
MK
PBLI
EPA-2

L, C, SG, Sim, IS

C, Sim, SOE,
MCQ, EOS

PC-3
MK
SBP-2,3
EPA-3

EMCP: Chapter 10: Diagnostic Testing

in the Emergency Department
CDEM: Diagnostic Testing

L, IS, S, EL

C, Sim, SOE,
MCQ, EOS, BE

PC-3,4
MK
EPA-10

CDEM: Diagnostic Testing; Approach

to: Cardiac Arrest, Chest Pain,
Diagnostic Testing
Current BLS/ACLS/PALS guidelines

EMCP: Chapter 7: Performing a

Complaint Directed H&P, and
Chapter 8: Data Gathering Skills, and
Chapter 11: Developing Your Plan of
Action
CDEM: The Approach to: Chest Pain,
Abdominal Pain, Respiratory Distress
and Altered Mental Status
EMCP: Chapter 9: Developing a CaseSpecific Differential Diagnosis
CDEM: The Approach to: Chest Pain,
Abdominal Pain, Respiratory Distress
and Altered Mental Status

M. C. Tews et al.

Focused Chief
Complaint History
and Physical (H&P)
Examination

Educational
Methods*

1.00

Acute Pain Control

0.82

Documentation

0.64

Disposition

0.82

Emergency Medicine
within the US Health
Care System

0.82

Professionalism

1.00

L, IS, C, S, EL

C, G, L, Sim,
SOE, MCQ,
EOS, BE

PC-9,13
MK
EPA-12

EMCP: Chapter 20: Procedural Skills

CDEM: Procedures

L, IS, C, SG

SOE, MCQ, EOS

PC-11
MK
ICS
EPA-12

CDEM: Acute Pain Control

L, C, S, SG

OSCE, P, RR, Sim,

SP, MCQ, EOS

PC-2,6
MK
ICS
SBP-3
EPA-5

EMCP: Chapter 15: Documentation

CDEM: Documentation of EM
Encounters

L, IS, C, S, SG

SOE, MCQ, EOS

PC-7
MK
ICS
SBP-2

EMCP: Chapter 13: Disposition of the

ED Patient and Chapter 14:
Discharge Instructions

L, IS, SG

SOE, MCQ

MK
PBLI
SBP-2

EMCP: Chapters 1: Introduction to the

Specialty of EM and Chapter 4:
Unique Educational Aspects of
Emergency Medicine and Chapter 5:
Differences between the ED, the
Office and the Inpatient Setting
CDEM: Emergency Medicine in the US
Healthcare System

L, IS, R, C, S

C, G, OSCE, RR,
SOE, SP, MCQ,
EOS, BE

ICS
PROF-1,2 SBP-1
EPA-9

EMCP: Chapter 23: Introduction to the

Core Competencies
CDEM: Professionalism

Continued

737

1. Describe the principles of basic

wound care.
2. Demonstrate the correct technique for simple wound closure
using simple interrupted sutures
and staples.k
1. Describe strategies for managing
pain using common oral and
parenteral medications.
2. Describe the use of common
local analgesics for wound repair
1. Document pertinent positives
and negatives from a focused
history and physical examination
for a patient with:
a. Chest pain
b. Abdominal paink
c. Shortness of breathk
d. Altered mental statusk
2. Describe the pertinent information needed for basic emergency
medicine procedural documentation.
3. Discuss the medicolegal aspects
of documentation in the ED.
1. Identify the different types of
disposition from the ED and factors that influence these decisions.
2. Describe the pertinent items to be
included in discharge instructions.
1. Discuss the function of the ED as
a safety net for patient care,
including 24/7 care, 24/7 faculty
coverage and the socioeconomic
challenges surrounding the uninsured and underinsured in obtaining care in the ED
2. Discuss the importance of interdisciplinary care within the ED.
1. Demonstrate professionalism
during interactions with patients,
families, ED staff, and consultants when caring for patients in
the ED.
2. Demonstrate a sensitivity toward
individual and cultural diversity
within the ED.
3. Demonstrate professionalism on
the rotation (e.g., appropriate
dress, language, punctuality).

Third-Year EM Medical Student Curriculum

Emergency
Department (ED)
Procedures

738

Table 1. Continued

Content

CVI

Communication

0.80

Motivation

1.00

Revised Learning Objectives

1. Demonstrate effective patientcentered communication and the
ability to develop and maintain
rapport with patients and their
families.
2. Demonstrate the ability to
communicate with a culturally
diverse patient population.
3. Demonstrate respectful communication with consultants,
nursing, and other staff in the ED.
1. Demonstrate willingness to see
patients, perform procedures,
and follow through on patient
diagnostic and therapeutic interventions.
2. Demonstrate willingness to
improve ones own knowledge by
engaging in self-directed learning
during clinical shifts.
3. Demonstrate ability to navigate
the literature to find evidencebased answers to clinical
questions.

Educational
Methods*

Assessment
Methods

ACGME Competencies,
ABEM Milestones,
and EPA

References

L, IS, R, C, S

C, G, OSCE, RR,
SOE, SP, MCQ,
EOS, BE

PBLI
ICS-1,2
PROF-1, 2
SBP-1,2
EPA-9

EMCP: Chapter 17: Interacting with

Consultants and Primary Care
Physicians and EMCP: Chapter 23:
Introduction to the Core
Competencies
CDEM: Communication

IS, R, C

C, G, L, RR, EOS

PC-6
MK
PBLI
EPA-7

EMCP: Chapter 22: How to Get the

Most Out of Your Emergency
Medicine Clerkship

M. C. Tews et al.

ABEM = American Board of Emergency Medicine; ALS = advanced life support; BLS = basic life support; CDEM = CDEMcurriculum.org; CVI = Content Validity Index; ED = emergency
department; EMCP = Emergency Medicine Clerkship Primer; EPA = Entrustable Professional Activities; PALS = pediatric advanced life support; SDOT = standardized direct observation
assessment tool.
* C = clinical ED setting; E = E-learning; IS = independent study/reading; L = lecture; R = reflection; S = simulation; SG = small group sessions.
C = checklist evaluation of live or recorded performance (e.g., SDOT, Mini-Clinical Evaluation Exercise); BE = bedside evaluations; DO = direct observation; EOS = end of shift evaluations; G = Global rating of live or recorded performance; L = procedure or case logs; MCQ = written examination; OSCE = objective structured clinical examination or standardized
patients; P = portfolios; RR = record review; S = patient surveys; Sim = simulations and task trainers; SOE = standardized oral examination.
ICS = interpersonal and communication skills; MK = medical knowledge; PBLI = practice-based learning and improvement; PC = patient care; PRO = professionalism; SBP = system-based
practice; PC-1 = Emergency Stabilization; PC-2 = Performance of a Focused History and Physical; PC-3 = Diagnostic Studies; PC-4 = Diagnosis; PC-5 = Pharmacotherapy; PC-6 = Observation
and Reassessment; PC-7 = Disposition; PC-8 = Multi-tasking; PC-9 = General Approach to Procedures; PC-10 = Airway Management; PC-11 = Anesthesia and Acute Pain Management; PC-12 =
Goal Directed Focused Ultrasound; PC-13 = Wound Management; PC-14 = Vascular Access; MK = Medical Knowledge; PROF-1 = Professional Values; PROF-2 = Accountability; ICS-1 = Patient
Centered Communication; ICS-2 = Team Management; PBLI = Practiced Based Performance Improvement; SBP-1 = Patient Safety; SBP-2 = Systems Based Management; SBP-3 = Technology.
EPA 1 = Gather a history and perform a physical examination; EPA 2 = Develop a prioritized differential diagnosis and select a working diagnosis following a patient encounter; EPA 3 =
Recommend and interpret common diagnostic and screening tests; EPA 5 = Provide documentation of a clinical encounter in written or electronic format; EPA 7 = Form clinical questions
and retrieve evidence to advance patient care; EPA 9 = Participate as a contributing and integrated member of an interprofessional team; EPA 10 = Recognize a patient requiring urgent or
emergent care, initiate evaluation and treatment, and seek help; EPA 12 = Perform general procedures of a physician.
k Objectives that cover both pediatric and adult resuscitation principles. ACGME = Accreditation Council for Graduate Medical Education; US = United States.

Third-Year EM Medical Student Curriculum

739

(24). Recent work has further defined the content for a pediatric EM clerkship curriculum (25). Although the Work
Group did not delineate pediatric-specific content, the objectives that are relevant for both adult and pediatric content are identified in Table 1.
Step 4: Educational Strategies
The core of any educational EM rotation is the clinical
experience, however, the number and duration of shifts
will vary, depending on the resources of the institution
or department (4,12). During their clinical time,
students should be exposed to the structure and
function of the ED, learn the approach to patients with
a variety of chief complaints, and begin to understand
diagnosis and basic management principles for
undifferentiated acutely ill or injured patients. This
approach is fundamentally different from that used for
the fourth-year student, who is expected to have experience with the basic approach to common complaints and
is focused on honing higher-level diagnostic and management skills (6). The difference in experience and
acumen between third and fourth-year students is a
particular challenge for institutions that offer EM experiences for both groups. Clinical educators must take
care to modify their expectations based on the students
level of training, and adjust their teaching accordingly.

Faculty should identify developmentally appropriate

learning opportunities for the third-year student in the
ED, such as assisting or performing procedures, practicing history and physical examination skills, interpreting clinical data, seeing interesting patient presentations,
or researching relevant clinical questions. Students
should be directed to evaluate patients appropriate for
their level of experience.
Outside of the clinical arena, there are several
educational methods that can be used to enhance student learning (2632). While there are numerous
effective educational methods, special consideration
should be given to simulation as an educational
method. Given the emphasis on practical skills and
high-acuity presentations in EM curricula, simulation
is particularly well suited to EM teaching. Simulation
has been shown to be more effective than traditional
instructional methods for improving procedural and
teamwork performance, and it allows learners to practice high stakes skills in a risk-free environment
(29,30). Each rotation director should select the most
appropriate method to meet learning objectives based
on their own clinical environment, institutional
resources, and the needs of their students. Several
possible strategies are listed in Table 2, along with positive and negative aspects of each, and are correlated to
the content areas in Table 1.

Table 2. Educational Strategies

Strategy
E-Learning (27,28,3338)

Small Group (3941)

Simulation (29,30,4244,4549)

Reflection (31,32,50)

Lecture (21)

Independent study/reading (3)

Positive Aspect
Electronic
Interactive
Learn at own pace
Creates a virtual environment
Requires little personnel time
Team-based/problem-based learning
Promotes discussion and clinical reasoning
Higher level of application
Promotes independent thought
Replicates clinical environment
Procedural/task training
Standardized scenarios
No risk of harm to patients
Ideal clinical exposure for novice students
Effective for teaching communication and
teamwork
Can be oral or written
Leads to meaningful learning
Formative or summative
Helps promote self-awareness of students
beliefs, values, and attitudes
Efficient
Large amount of information in short time
Consistent coverage of objectives
Large audience reached
Can be done by podcast/electronic media
asynchronously
Student sets own pace
No need for direct faculty involvement
Can be delivered electronically

Negative Aspect
Significant start up expense
Large amount of time to create

Faculty development needed strong facilitator

Costly
Time consuming
Heavy personnel commitment
Requires institutional resources

Takes time to become comfortable with

Requires faculty time to read and interpret what
student says
Minimal interaction with teacher and student

Students need to be motivated

May need direction on what to focus on

740

Step 5: Implementation
New rotation directors may take on the daunting task of
creating or redesigning an EM experience, often with
minimal guidance or direction. In addition to building
skills in teaching, curriculum development, and student
assessment, rotation directors must be familiar with the
practical aspects of overseeing a rotation (5153). They
must know and follow their institutional policies and
national standards (22). Specific LCME requirements
supported by this curriculum are listed in Appendix 3,
which may serve as a resource for educators negotiating
the initiation of a mandatory EM clerkship within their
medical schools.
There are several resources available to assist with implementation. One is the Guidebook for Clerkship Directors produced by The Alliance for Clinical Education,
which is a comprehensive resource for clerkship directors
across specialties (54). The Clerkship Coordinators
Handbook can provide guidance on administrative duties
for the rotation (55). Kerns Curriculum Development in
Medical Education: A Six Step Approach provides a practical and systematic way to approach the implementation
phase of a curriculum (14). While Kern outlines a broad
range of factors that must be taken into account when implementing a curriculum, potential barriers to success
merit special consideration.
Possibly the biggest challenge is teaching students
with differing levels of clinical experience, depending
on the timing of the rotation during the third year. Faculty
and residents involved in teaching medical students may
require guidance in adjusting their expectations and practices to meet the needs of learners in various stages of
their training. We chose the Must, Should, Can model
to allow for this flexibility while maintaining consistency
in teaching the core aspects of EM (Must). Novice
learners in the ED must be provided with close supervision to ensure patient safety.
A second challenge is time constraints in the ED
setting. Third-year students may require more faculty
and resident guidance than more experienced fourth-year
students. They may not have the clinical experience
needed to evaluate acuity or independently manage certain
aspects of patient care. Balancing the clinical and educational missions of the department is essential, and educators may need to advocate for resources to ensure
adequate teaching for their students without compromising
departmental operations. Faculty and residents involved
with teaching may also require instruction on how to incorporate education for the novice learner into their clinical
work in an efficient and effective manner.
Third, EM education focuses on high-acuity presentations and stabilization procedures. While it is possible to
offer a conceptual background on these topics through

M. C. Tews et al.

lectures or reading, experiential learning techniques are

more effective for facilitating mastery of skill objectives
(4244). While labor intensive for faculty, this form of
learning is ideal for the third-year student who has not
developed the clinical acumen on how to approach
high-acuity patients. The benefits are considerable,
including improved educational outcomes, high levels
of learner satisfaction, and contribution to accreditation
performance (29,30).
Fourth, it may be difficult to find time for EM in
an already crowded third-year medical school
schedule. The addition of a required clerkship during
this time may require adjustments to another part of
the existing curriculum. Potential solutions include
an abbreviated 2-week rotation, an elective or selective rotation, or an interdisciplinary rotation with other
specialties like surgery, critical care medicine, or anesthesiology (12).
Finally, the effect of a third-year EM rotation on an existing fourth-year EM rotation must be considered. The
curriculum we provide serves as a basic foundation on
which to build and expand the fourth-year experience.
Therefore, it is the opinion of this Work Group that this
curriculum would enhance rather than diminish the
importance of the fourth-year EM rotation.
Step 6: Evaluation and Feedback
The LCME requires that a medical school ensures a system of formative and summative medical student assessment (22). Whenever possible, multiple methods of
assessment should be used, tools should be linked to nationally accepted standards or metrics, and evidence of
reliability and validity of assessment data should be assessed and monitored closely (21). Methods of assessment for a third-year EM rotation director to consider
are correlated with the content areas listed in Table 1
and Appendixes 1 and 2. These match the categories
recommended in the Emergency Medicine Milestones
Project (15).
Clinical Assessment of the Student
Formative feedback should ideally occur regularly
throughout the rotation. Daily clinical shift evaluations
can provide immediate formative feedback, if discussed
with the student at the end of their shift (21). Formal
formative mid-rotation feedback needs to be in place
for required clerkships lasting 4 weeks or longer, and
must be done early enough to allow sufficient time for
remediation, ideally at the midpoint of the clerkship
(56,57). Clerkship directors should track and document
that these sessions have occurred, and be prepared to
account for this at future LCME site visits.

Third-Year EM Medical Student Curriculum

Compilation of daily scores and narrative comments

combined with direct observation and testing form a major component of the summative end of clerkship assessments, including the final grade (58). Direct observation
of students engaged in clinical encounters is an LCME
requirement for required clerkships, and should be a
part of the assessment of students clinical performance.
Several clinical observation tools have been discussed in
the literature, but none of which have demonstrated reliability and validity in the medical student population (59
62). An example of a direct observation tool can be found
in the Medical Student Educators Handbook (21).
Assessment instruments should be the same for all sites
in a multi-site clerkship.
The ED can be a challenging environment for clinical
assessment. Students rarely work longitudinally with the
same preceptor, limiting the observation period on which
assessments can be based. The fast pace of the ED makes
it difficult to find time to observe students and hear their
presentations. The high acuity of ED patients can make it
difficult to meaningfully involve novice students in clinical activities, and they are often relegated to an observer
role. It is essential that faculty and residents involved with
teaching receive education about how to optimize their
interactions with students at differing levels of experience
in the clinical area, and specific instruction and calibration to ensure consistent assessment practices.
Nonclinical Assessment of the Student
Written, oral, and practical examinations can objectively
measure the third-year medical students knowledge and
skill base. Knowledge can be tested using independently
written tests or national examinations. The former can be
more readily adjusted to assess unique aspects of individual rotations, while the latter generally have the advantage of greater reliability and validity evidence (9).
There are two widely available national examinations:
the National EM M4 Exam, which is an online examination recently developed by CDEM (http://www.
saemtests.org), and the National Board of Medical Examiners (NBME) Advanced Clinical Exam in EM (6365).
It should be emphasized that both of these examinations
are designed based on the curriculum for fourth-year students, and their appropriateness for third-year students
has not been established (6,65). Another option for
third-year rotation directors is creation of an institutionspecific examination based on the third-year curriculum
content. When creating test items for an independently
written examination, the NBME Item Writing Manual
is a valuable resource to ensure items are of high quality,
improving test validity and reliability (9).
Simulation-based examinations and Objective Structured Clinical Examinations are particularly well suited

741

to assess psychomotor and problem-solving skills,

although they are more resource-intensive than traditional testing methods (6670). Other assessment
techniques may include presentations or reports on
EM topics, take-home assignments, such as electrocardiogram and radiology projects, and exercises in
evidence-based medicine. For all assessment methods,
consideration must be given to ensure test security, to
avoid duplication of questions between third- and
fourth-year rotations, and to maintain consistency in
grading between individuals and sites.
Curriculum Maintenance and Enhancement
Continuous process improvement is important to ensure a
consistently high-quality curricular experience. A thorough description of how to approach this process is outlined by Kern et al. (14). Educators should consider
student satisfaction data as well as educational outcome
metrics in deciding if and how to revise the rotation. In
order to maintain and update this curriculum, the rotation
learning objectives and resources will be kept online and
periodically updated at http://www.cdemcurriculum.org/.
CONCLUSIONS
Emergency medicine has increasingly become an established part of medical school curricula, and many institutions teach EM during the third year. The goals and
consensus-derived learning objectives provided here
form the basis of this third-year EM medical student curriculum. Discussion of educational methods, considerations for implementation, and information regarding
feedback and evaluation are included to assist rotation directors in implementing this curriculum at their institutions. To address national standards, LCME guidelines
specifically supported by this curriculum are outlined,
and may provide additional guidance to programs attempting to establish a third-year EM clerkship. Each
institution should review their available resources to
ensure the Must content areas are covered and look
for opportunities to include Should and Can content
where appropriate.
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743.e1

Appendix 1. Should Third-Year EM Curriculum Content

Content
The Approach to the
Undifferentiated Patient
Stabilization of the Acutely Ill
Patient

Vital Signs

Basic and Advanced Life

Support Techniques

Focused Chief Complaint

History and Physical (H&P)
Examination

Chief Complaint Differential

Diagnosis

Revised Learning Objectives

Educational Methods*

Already covered in must

objectives.
1. Identify potential causes L, IS
of acute blood loss in
gastrointestinal (GI)
bleeding.
2. Describe the clinical
approach to the
bleeding patient.
1. Define a hypertensive
L, IS
crisis.

1. Demonstrate how to
L, S, EL
perform electrical cardioversion in the appropriate clinical setting.
2. Demonstrate how to
perform transcutaneous
pacing in the appropriate clinical setting.
1. Perform a focused H&P L, IS, C, S, EL, SG
for a patient presenting
with:
a. Headache
b. Focal neurologic
deficit
c. GI bleeding
d. Vaginal bleeding/
pelvic pain
e. Toxic ingestion
L, C, E, SG, S, IS

ACGME Competencies,
ABEM Milestones, and EPA

References

C, G, OSCE, Sim, SOE, MCQ

PC-1, 2, 3, 4, 5, 6, 7
MK

CDEM: Stabilization of the

Acutely Ill Patient; Approach
to: Shock; Approach to
Gastrointestinal bleeding;
Approach to: Trauma

SOE, MCQ, EOS

PC-1
MK

C, G, Sim, MCQ

PC-1,4,6, 9
MK
ICS-2

EMCP: Chapter 11:

Developing Your Plan of
Action
CDEM: Approach to the
Undifferentiated Patient
CDEM: Basic and Advanced
Life Support
Current BLS/ACLS/PALS
guidelines

C, G, OSCE, Sim, SOE, SP,

MCQ, EOS, BE

PC-2
MK
PBLI

C, Sim, SOE, MCQ, EOS

PC-4
MK
PBLI

EMCP: Chapter 7: Performing

a Complaint Directed H&P,
and Chapter 8: Data
Gathering Skills, and
Chapter 11: Developing
Your Plan of Action
CDEM: The Approach to:
Headache, Neurologic
Complaint, GI Bleed,
Vaginal Bleeding/Pelvic
Pain, Poisoning
EMCP: Chapter 9: Developing
a Case-Specific Differential
Diagnosis
CDEM: The Approach to:
Headache, Neurologic
Complaint, GI Bleed,
Vaginal Bleeding/Pelvic
Pain, Poisoning

Continued

M. C. Tews et al.

1. List the common and

life-threatening causes
of:
a. Headache
b. Focal neurologic
deficit
c. GI bleeding
d. Vaginal bleeding/
pelvic pain
e. Toxic ingestion

Assessment Methods

Content
Diagnostic testing

Electrocardiogram (ECG)/
Rhythm Recognition

Emergency Department (ED)

Procedures

Revised Learning Objectives

Educational Methods*

ACGME Competencies,
ABEM Milestones, and EPA

References

Sim, SOE, MCQ, EOS

PC-3
MK
SBP-1, 2, 3

EMCP: Chapter 10: Diagnostic

Testing in the Emergency
Department
CDEM: Diagnostic Testing

Sim, SOE, MCQ, EOS, BE

PC-3,4, 5
MK
SBP-1

CDEM: Approach to: Cardiac

Arrest, Diagnostic Testing
Current BLS/ACLS guidelines

C, G, Sim, SOE, MCQ, EOS,

BE

PC-9, 13
MK
SBP-1

EMCP: Chapter 20: Procedural

Skills
CDEM: Procedures

743.e2

Laboratory studies
L, C, SG, Sim, IS
1. Describe the indications
and uses of the
following laboratory
studies, and what is
considered normal vs.
abnormal:
a. Arterial blood gas
b. D-dimer
c. Quantitative b-HCG
Radiographic studies
1. Discuss the use of clinical decision rules for
determining which patients with traumatic
brain injury require a
noncontrast head
computed tomography
(CT) scan
2. Interpret a noncontrast
CT scan of the head for
the different types
(epidural, subdural,
subarachnoid, intraparenchymal) of intracranial
bleeding
Bedside testing
1. Describe the indications
and interpretation of a
stool guaiac test for a
patient with potential GI
bleeding
1. Identify the following
L, IS, S, EL
rhythms on ECG or
rhythm strip and
describe their initial
treatment:
a. Supraventricular
tachycardia
b. Atrial fibrillation
c. Atrial flutter
d. Second- and thirddegree heart block
1. Discuss the manageL, IS, C, S, EL
ment of a subcutaneous
abscess
2. Discuss the indications
and contraindications of
a lumbar puncture for a
patient with a headache

Assessment Methods

Third-Year EM Medical Student Curriculum

Appendix 1. Continued

Acute Pain Control

Bedside Ultrasonography

Documentation
(when applicable)

C, G, Sim, SOE, SP, MCQ

PC-1, 3, 4, 9, MK
ICS-2
SBP-1, 2

CDEM: The Approach to

Trauma; Procedures

C, G, Sim, SOE, MCQ

PC-3,14
MK
PBLI

CDEM: Diagnostic Testing

RR, Sim, SP, MCQ, EOS

PC-2, 6
MK
SBP-2,3

EMCP: Chapter 15:

Documentation
CDEM: Documentation of EM
Encounters

Continued

M. C. Tews et al.

Disposition

1. Describe the initial

L, IS, C, S
management of extremity fractures and
dislocations
2. Demonstrate the correct technique for
immobilization of the
spine
3. List the criteria (NEXUS
or Canadian) for identifying which patients
require cervical spine
imaging vs. those who
can be cleared clinically.
4. Demonstrate clinical
assessment of the spine
and removal of cervical
collar and backboard
when indicated
Already covered in must
objectives
1. Discuss the indications L, IS, EL, C, S, SG
for bedside ultrasound
in the ED
2. Describe the indications
for obtaining a bedside
ultrasound evaluating
for a pericardial effusion
3. Describe the indications
for obtaining a bedside
ultrasound evaluating
for an abdominal aortic
aneurysm
1. Document pertinent
L, C, S, SG
positives and negatives
from a focused history
and physical examination for a patient with:
a. Headache
b. Focal neurologic
deficit
c. Gastrointestinal
bleeding
d. Vaginal bleeding/
pelvic pain
e. Toxic ingestion
Already covered in must
objectives

743.e3

Traumatic and Orthopedic

Injuries

Content

Revised Learning Objectives

Educational Methods*

Emergency Medicine within

the US Healthcare System

1. Explain the use of a

L, IS, SG
systems approach to
patient care (STEMI,
stroke, trauma, etc.)
2. Describe EMTALA
guidelines and how it
relates to ED transfers of
patients

Emergency Medical Services

Already covered in must

objectives
Discuss the role of the
L, IS, R, C, S
emergency physician in
dealing with challenging
situations in the ED (e.g.,
victims of child abuse, elder
abuse, sexual assault,
emancipated minors,
patients who refuse medical
care)
1. Discuss strategies for
L, IS, R, C, S
delivering bad news
2. Discuss strategies for
dealing with consultants
3. Discuss the importance
of safe handoff strategies

Professionalism

Communication

Motivation

1. Demonstrate follow
IS, R, C
through on admitted patients hospital course

Assessment Methods

ACGME Competencies,
ABEM Milestones, and EPA

References

SOE, MCQ

PC-1
MK
PBLI
SBP-2

EMCP: Chapters 1:
Introduction to the Specialty
of EM and Chapter 4: Unique
Educational Aspects of
Emergency Medicine and
Chapter 5: Differences
between the ED, the Office
and the Inpatient Setting
CDEM: Emergency Medicine in
the US Healthcare System

C, G, OSCE, RR, SOE, SP,

MCQ, EOS, BE

PC-1, 2, 3, 4 MK
ICS-1, 2 PROF-1, 2 SBP-1, 2

EMCP: Chapter 23:

Introduction to the Core
Competencies
CDEM: Professionalism

C, G, OSCE, RR, SOE, SP,

MCQ, EOS, BE

PC-1, 6, 7
PBLI
ICS-1,2
PROF-1, 2SBP-2

C, G, L, RR, EOS

PBLI
PROF-1,2
SBP-2

EMCP: Chapter 17: Interacting

with Consultants and
Primary Care Physicians
and EMCP: Chapter 23:
Introduction to the Core
Competencies
CDEM: Communication
EMCP: Chapter 22: How to Get
the Most Out of Your
Emergency Medicine
Clerkship

743.e4

ABEM = American Board of Emergency Medicine; ALS = advanced life support; ACGME = Accreditation Council for Graduate Medical Education; BLS = basic life support; CDEM =
CDEMcurriculum.org; EMCP = Emergency Medicine Clerkship Primer; EMTALA = Emergency Medical Treatment and Labor Act; EPA = Entrustable Professional Activities; HCG = human
chorionic gonadotropin; PALS = pediatric advanced life support; STEMI = ST segment elevation myocardial infarction; US = United States.
* C = clinical ED setting; E = E-learning; IS = independent study/reading; L = lecture; R = reflection; S = simulation; SG = small group sessions.
C = checklist evaluation of live or recorded performance (e.g., SDOT, Mini-Clinical Evaluation Exercise); BE = bedside evaluations; DO = direct observation; EOS = end of shift evaluations; G = Global rating of live or recorded performance; L = procedure or case logs; MCQ = written examination; OSCE = objective structured clinical examination or standardized
patients; P = portfolios; RR = record review; S = patient surveys; Sim = simulations and task trainers; SOE = standardized oral examination.
ICS = interpersonal and communication skills; MK = medical knowledge; PBLI = practice-based learning and improvement; PC = patient care; PRO = professionalism; SBP = systembased practice; PC-1 = Emergency Stabilization; PC-2 = Performance of a Focused History and Physical; PC-3 = Diagnostic Studies; PC-4 = Diagnosis; PC-5 = Pharmacotherapy; PC-6
= Observation and Reassessment; PC-7 = Disposition; PC-8 = Multi-tasking; PC-9 = General Approach to Procedures; PC-10 = Airway Management; PC-11 = Anesthesia and Acute Pain
Management; PC-12 = Goal Directed Focused Ultrasound; PC-13 = Wound Management; PC-14 = Vascular Access; MK = Medical Knowledge; PROF-1 = Professional Values; PROF-2
= Accountability; ICS-1 = Patient Centered Communication; ICS-2 = Team Management; PBLI = Practiced Based Performance Improvement; SBP-1 = Patient Safety; SBP-2 = Systems
Based Management; SBP-3 = Technology.
EPA 1 = Gather a history and perform a physical examination; EPA 2 = Develop a prioritized differential diagnosis and select a working diagnosis following a patient encounter; EPA 3 =
Recommend and interpret common diagnostic and screening tests; EPA 5 = Provide documentation of a clinical encounter in written or electronic format; EPA 7 = Form clinical questions
and retrieve evidence to advance patient care; EPA 9 = Participate as a contributing and integrated member of an interprofessional team; EPA 10 = Recognize a patient requiring urgent or
emergent care, initiate evaluation and treatment, and seek help; EPA 12 = Perform general procedures of a physician.

Third-Year EM Medical Student Curriculum

Appendix 1. Continued

743.e5

Appendix 2. Can Third-Year Emergency Medicine Curriculum Content

Content
The Approach to the
Undifferentiated Patient
Stabilization of the Acutely Ill
Patient

Vital Signs
Basic and Advanced Life
Support Techniques

Focused Chief Complaint

History and Physical
Examination
Chief Complaint Differential
Diagnosis
Diagnostic Testing

Electrocardiogram (ECG)/
Rhythm Recognition

Educational Methods*

Already covered in must or

should objectives.
1. Describe the approach L, IS
and stabilization of the
traumatically injured
patient with acute blood
loss.
Already covered in must or
should objectives.
1. List the steps in rapid
L, S, EL
sequence intubation.
2. Demonstrate the technique for placement of
an endotracheal tube.
3. Explain the purpose and
uses of bilevel positive
airway pressure.
Already covered in must or
should objectives.
Already covered in must or
should objectives.
Laboratory studies
L, C, SG, Sim, IS
1. Describe the indications, utilization, and
interpretation of a btype natriuretic peptide
1. Identify the following
L, IS, S, EL
patterns on ECG or
rhythm strip and
describe their clinical
significance and initial
treatment:
a. Wolf-Parkinson
White syndrome
b. Brugada syndrome
c. Osborn waves
d. Hypo- and hyperkalemia
e. Hypo- and hypercalcemia
1. Describe the indicaL, IS, C, S, EL
tions, contraindications
and correct technique
for placing a central
venous line (see
Bedside Ultrasonography).

Assessment Methods

ACGME Competencies,
ABEM Milestones, and EPA

References

C, G, OSCE, Sim, SOE, MCQ

PC-1, 5, 6
MK

CDEM: Stabilization of the

Acutely Ill Patient; Approach
to: Shock; Approach to
Gastrointestinal bleeding;
Approach to: Trauma

C, G, Sim, MCQ

PC-10
MK

Current BLS/ACLS/PALS
guidelines
CDEM: Basic and Advanced
Life Support

Sim, SOE, MCQ, EOS

PC-3
MK
SBP-2,3

EMCP: Chapter 10: Diagnostic

Testing in the Emergency
Department
CDEM: Diagnostic Testing

Sim, SOE, MCQ, EOS, BE

PC-3,4,5
MK

CDEM: Approach to: Cardiac

Arrest, Current BLS/ACLS
guidelines
CDEM: Diagnostic Testing

C, G, Sim, SOE, MCQ, EOS,

BE

PC-9,12,14
MK

EMCP: Chapter 20: Procedural

Skills
CDEM: Procedures

M. C. Tews et al.

Emergency Department (ED)

Procedures

Revised Learning Objectives

Acute Pain Control

Bedside Ultrasonography

Documentation
Disposition
Emergency Medicine within
the US Healthcare System

Emergency Medical Services

(EMS)

1. Describe the approach L, IS, C, S

to the traumatically
injured patient with blunt
and penetrating trauma.
2. Demonstrate a primary
and secondary survey in
a traumatically injured
patient.
Already covered in must or
should objectives.
1. Describe the indications L, IS, EL, C, S, SG
for obtaining a bedside
ultrasound in trauma.
2. Define a positive FAST
examination in the
setting of trauma.
3. Describe the use of ultrasound in the placement peripheral and
central venous lines.
Already covered in must or
should objectives.
Already covered in must or
should objectives.
1. Discuss the history of
L, IS, SG
emergency medicine
and its evolution into a
medical specialty.
2. Discuss the types of
career opportunities
available in EM.

PC-1,2
MK
SBP-2,3

CDEM: The Approach to

Trauma; Traumatic and
Orthopedic Procedures

C, G, Sim, SOE, MCQ

PC-3,14
MK
PBLI

CDEM: Diagnostic Testing

SOE, MCQ

MK
PBLI
SBP-2

SOE, MCQ

PC-1
MK
PBLI
SBP-1,2

EMCP: Chapters 1:
Introduction to the Specialty
of EM and Chapter 4:
Unique Educational
Aspects of Emergency
Medicine and Chapter 5:
Differences between the
ED, the Office and the
Inpatient Setting
CDEM: Emergency Medicine
in the US Health Care
System
CDEM: Emergency Medicine
in the US Health Care
System

Continued

743.e6

1. Describe the function of L, IS, SG

EMS in the health care
system.
2. Differentiate between
basic and advanced life
support transport in the
prehospital setting.
3. Discuss the factors that
go into deciding to
transport a patient by
ground vs. air.
4. Discuss regional trauma
center designations and
the decision where to
transport an injured patient.

C, G, Sim, SOE, SP, MCQ

Third-Year EM Medical Student Curriculum

Traumatic/Orthopedic Injuries

Content
Professionalism
Communication
Motivation

Revised Learning Objectives

Educational Methods*

Assessment Methods

ACGME Competencies,
ABEM Milestones, and EPA

References

743.e7

Appendix 2. Continued

Already covered in must or

should objectives.
Already covered in must or
should objectives.
Already covered in must or
should objectives.

ABEM = American Board of Emergency Medicine; ALS = advanced life support; ACGME = Accreditation Council for Graduate Medical Education; BLS = basic life support; CDEM =
CDEMcurriculum.org; EMCP = Emergency Medicine Clerkship Primer; FAST = focused assessment with sonography in trauma; PALS = pediatric advanced life support; US = United
States.
* C = clinical ED setting; E = E-learning; IS = independent study/reading; L = lecture; R = reflection; S = simulation; SG = small group sessions.
C = checklist evaluation of live or recorded performance (e.g., SDOT, Mini-Clinical Evaluation Exercise); BE = bedside evaluations; DO = direct observation; EOS = end of shift evaluations; G = Global rating of live or recorded performance; L = procedure or case logs; MCQ = written examination; OSCE = objective structured clinical examination or standardized
patients; P = portfolios; RR = record review; S = patient surveys; Sim = simulations and task trainers; SOE = standardized oral examination.
ICS = interpersonal and communication skills; MK = medical knowledge; PBLI = practice-based learning and improvement; PC = patient care; PRO = professionalism; SBP = systembased practice; PC-1 = Emergency Stabilization; PC-2 = Performance of a Focused History and Physical; PC-3 = Diagnostic Studies; PC-4 = Diagnosis; PC-5 = Pharmacotherapy; PC-6
= Observation and Reassessment; PC-7 = Disposition; PC-8 = Multi-tasking; PC-9 = General Approach to Procedures; PC-10 = Airway Management; PC-11 = Anesthesia and Acute Pain
Management; PC-12 = Goal Directed Focused Ultrasound; PC-13 = Wound Management; PC-14 = Vascular Access; MK = Medical Knowledge; PROF-1 = Professional Values; PROF-2
= Accountability; ICS-1 = Patient Centered Communication; ICS-2 = Team Management; PBLI = Practiced Based Performance Improvement; SBP-1 = Patient Safety; SBP-2 = Systems
Based Management; SBP-3 = Technology.
EPA 1 = Gather a history and perform a physical examination; EPA 2 = Develop a prioritized differential diagnosis and select a working diagnosis following a patient encounter; EPA 3 =
Recommend and interpret common diagnostic and screening tests; EPA 5 = Provide documentation of a clinical encounter in written or electronic format; EPA 7 = Form clinical questions
and retrieve evidence to advance patient care; EPA 9 = Participate as a contributing and integrated member of an interprofessional team; EPA 10 = Recognize a patient requiring urgent or
emergent care, initiate evaluation and treatment, and seek help; EPA 12 = Perform general procedures of a physician.

M. C. Tews et al.

Third-Year EM Medical Student Curriculum

743.e8

Appendix 3. Liaison Committee on Medical Education Requirements Addressed by Third-Year Emergency Medicine
Curriculum* (22)
LCME

Implication

Support Provided by This Curriculum

ED-1

Faculty must define the objectives for curriculum content and

provide the basis for evaluating the effectiveness of the
educational program.

ED-1A

Objectives of the educational program must be stated in

outcome-based terms that allow evaluation of the students
progress.

ED-3

The objectives of the program must be made known to all

students and to faculty and residents responsible for the
medical student education.

ED-8

There must be comparable educational experiences and

equivalent methods of evaluation across all sites in a multisite rotation.

ED-19

Medical schools must offer specific instruction in

communication skills.

ED-27

There must be ongoing assessment that assures students

have acquired the core clinical skills, behaviors, and
attitudes specified in the educational objectives.

ED-30

Clerkship directors must implement a system of formative and

summative evaluation of student achievement in each
clerkship

ED-31

Medical students must receive feedback early enough to

allow time for remediation

ED-34

The programs faculty is responsible for the design and

implementation of the curriculum, including the
development of specific course objectives and evaluation
methods to assess achievement of these objectives, and
assessment of course and teacher quality.

In developing this curriculum, our consensus group

determined which elements of knowledge, skills, and
attitudes were appropriate to teach third-year medical
students and developed these into measurable learning
objectives for educators to use.
This curriculum lists the learning objectives in outcome-based
terms. Various assessment tools are identified that allow
evaluation of the medical students performance and
progression throughout the clerkship.
This curriculum delineates specific learning objectives in
outcome-based terms that can be shared with the medical
students, supervising residents, and attending physicians
to ensure consistent education and evaluation of the
students.
This curriculum was designed to insure that all third-year
medical student emergency medicine (EM) clerkships have
consistent achievable objectives across all institutional
sites (Must objectives). These should be assessed by
using daily shift evaluation forms as well as end of clerkship
summative assessments. These forms should be
consistent across sites.
EM allows students to observe and practice a wide range of
doctorpatient and inter-professional communication
skills. The emergency department provides vast
opportunity to teach and assess students communication
skills with these interactions and is a necessary component
of this curriculum.
The learning objectives in this curriculum delineate the
knowledge, skills, and attitudes taught in this curriculum.
We suggest various methods for assessing the acquisition
of these objectives, including direct observation, formative
and summative evaluations and written exams.
Daily clinical shift forms provide formative feedback.
Compilation of these daily scores and narrative comments
combined with direct observation and testing form the
basis for summative assessment resulting in the final grade
as well as mid- and end-of-clerkship feedback.
The structure of EM allows students to be evaluated by
supervising residents and faculty on each shift. Written and
real-time feedback provides continuous performance data
that can be used during mid-rotation feedback to identify
areas in need of remediation.
This curriculum includes learning objectives that were
deemed necessary (Must) for third year medical students
by consensus agreement of experts in the field of EM
education. Additional objectives for faculty to choose from
are included in the Should and Can content, which can
be chosen based on department or institutional resources.
Methods of evaluation have been cited in the EM literature
and students must also have the opportunity to evaulate the
teachers and the clerkship.

* Since submission of this article, the Liaison Committee on Medical Education has modified their standards. The new standards publication is effective for the 2015-16 academic year and has a useful table that compares these 2014-15 standards to the updated standards.