Scholarly Activity Program Requirements: The Review Committee‐Emergency Medicine (RC‐EM) Perspective

In this issue of Academic Emergency Medicine, Geyer et al.1 have provided insights regarding how the program requirements of the Accreditation Council for Graduate Medical Education (ACGME) Review Committee for Emergency Medicine (RC-EM) are interpreted and put into practice by residency training programs. The article describes challenges and barriers for residents to accomplish scholarly activity, which may bring to light areas for both performance improvement for specific programs and opportunities for EM programs to work collaboratively to develop solutions. Of special interest is an attempt to link specific resident scholarly activity to early career choice. The RC-EM would suggest that all residents, regardless of their chosen career path, should understand the principles of research and how to appraise the medical literature. Writing on behalf of the RC-EM, we hope to promote understanding of the rationale for the scholarly activity requirements as well as to encourage flexibility in the approach to satisfying these requirements. The objective of the RC-EM scholarly activity requirement is for residents to establish and promote lifelong learning practices and to develop the necessary skills to provide evidence-based patient care. Specifically, both the medical knowledge and practice-based learning and improvement competencies speak to skill sets that reflect the scholarly activity requirements. For medical knowledge, residents are expected to be able to demonstrate evidence-based decision-making and problem solving (Program Requirement [PR] IV.A.5.b).(2)).2 For the practice-based learning and improvement competency, residents must be able to appraise and assimilate scientific evidence to improve patient care (PR IV.A.5.c).2 EM's Milestone 19 further describes the progression of these skills from being able to describe evidence-based principles (Level 1) to applying the concepts in performance improvement and clinical care (Level 4).3 Underscoring the importance of developing scholarly skills in residency, The Model of Clinical Practice of Emergency Medicine (EM Model) aligns with the core competencies and defines physician tasks that speak to a need for performance improvement and lifelong learning, including the ability to interpret and apply the medical literature to improve patient care, provide evidence-based medicine, practice knowledge translation, and promote research.4 The RC-EM requires the program's curriculum to advance residents' knowledge of the principles of research, which includes how it is conducted, evaluated, explained to patients, and applied to patient care (PR.IV.B.1).2 Required didactic sessions that promote this knowledge include journal reviews and research seminars (PR.IV.A.3.a).2 Methods required to manage educational curricula include evidence-based learning (PR.IV.A.3.a).(2)).2 It was surprising that in their survey, almost one-quarter of programs do not require journal clubs in their didactic schedules, even though this is a clear EM program requirement. Those programs should implement this educational experience for residents to learn how to appraise the medical literature. As stated in the Common Program Requirements for all specialties, the RC-EM requires that residents should participate in scholarly activity (PR.IV.B.2.), but does not require original research. As far back as 1997, EM academic leaders recommended that all residents should be instructed how to review medical literature and learn research methodology; however, they concluded that focused research experience should be targeted toward residents interested in an academic career.5 For reference, the frequently asked questions (FAQs) for requirement IV.B.2 provide examples of a variety of scholarly activities acceptable to the committee such as preparation of a review or case report, participation in or implementation of an original research project, or a quality improvement project.6 Therefore, quality activities, review papers, and more traditional research are all examples of resident scholarship that would meet RC-EM expectations. A minority of programs allowed for a local lecture to meet the requirements; depending on the content, that alone may not fulfill the spirit of the scholarly requirement. The RC-EM sets minimum requirements and programs can and should strive to exceed these and develop their program aims within the resources of their institutional environments.7 For example, if most of the graduates of the program pursue community medicine, quality improvement projects or clinical reviews may be of more practical value to those residents. Other programs that aim to train academicians may require original research and other experiences to prepare their graduates. While it may be very appropriate to require research for residents preparing for academic careers, the authors demonstrate that a program research requirement alone does not predict or separate out programs more likely to train academicians. So how does the resident scholarly activity requirement and didactic curriculum relate to faculty scholarly requirements? The primary intent of faculty requirements is to promote an educational environment (PR.II.B.1.b).2 There is an expectation that faculty must actively participate in journal clubs and clinical conferences (PR.II.B.5.a) to impart their experience and perspective to add to the educational experience for residents.2 Not every EM clinician regularly reads the current literature and incorporates new evidence into their practices. Therefore, those clinicians are not the ideal role models for residents who need to learn those skills. To identify qualified teaching faculty, it is critical that faculty (as a whole and not as each individual) maintain an environment of scholarship and inquiry, including active research (PR.II.B.5), as evidence of skills requisite to teach evidence-based medicine to residents.2 Scholarship for some program faculty should include peer funding, publications (original research and review articles in peer reviewed journals), textbook chapters, presentations in regional and national professional society meetings, and participation in national or educational organizations ((PR II.B.5.b).(1–4)).2 Faculty scholarly activity requirements are about peer acknowledgment of a faculty's skill in maintaining up-to-date knowledge. To be invited to teach at a national conference, contribute to national clinical guidelines, write a chapter, serve as a peer reviewer or editor of a journal, or achieve grant funding for a proposal requires that peers have determined the individual to be able to incorporate new evidence and be up to date. While not all faculty teachers are expected to be researchers, at least some must have that skill, and again, this can be in quality, safety, clinical research, basic science, or any other relevant area. It is important and required that research faculty are not isolated in their laboratories, but also interact with the residents they teach in clinical discussions, rounds, journal clubs, and conferences (PR II.B.5.a).2 In this capacity, faculty can mentor and educate residents to develop their lifelong learning skills. The rationale for resident and faculty scholarly activity is clear. The low frequency of citations for inadequate resident scholarly activity suggests that EM programs do not have difficulty meeting this requirement (Table 1). Faculty scholarly activity is more challenging, especially with the requirement that core faculty should have one scholarly activity every year, including a peer-reviewed publication every 5 years. There are a smaller number of programs where support of faculty research is considered inadequate (Table 1). Although the intent is clear, the correlation of successful completion of the scholarly activity requirement has not yet been demonstrated to assure that the overall goals of residents developing lifelong learning skills have been met. Perhaps these skills can be better assessed measuring the attainment and progression of milestones throughout each resident's training. In summary, each specialty and each fellowship may value scholarly activity differently, and each program has the flexibility to implement the requirement in its own way with the goal of giving the residents the skills they need to provide evidence-based care now and in the future. Faculty scholarly activity demonstrates that faculty possess and practice the skills to maintain a learning environment that can teach the residents the skills they need to provide evidence-based care now and in the future. The authors' conclusion that there exists a lack of consistency regarding the scholarly activity requirement among programs merely points to the fact that programs are free to interpret how this requirement can best be met within the aims and resources of each individual program. The authors thank the ACGME for providing scholarly activity data.