The 2005 Model of the Clinical Practice of Emergency Medicine: The 2007 Update

Emergency medicine is the only medical specialty that has a scientifically derived and commonly accepted description of the domain of its clinical practice. That document, The Model of the Clinical Practice of Emergency Medicine (EM Model), was developed through the collaboration of six organizations: the American Board of Emergency Medicine (ABEM), the administrative organization for the project, the American College of Emergency Physicians (ACEP), the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents’ Association (EMRA), the Residency Review Committee for Emergency Medicine (RRC-EM), and the Society for Academic Emergency Medicine (SAEM). Development of the EM Model was based on an extensive practice analysis of the specialty. The practice analysis relied on both empiric data gathered from actual emergency department visits and several expert panels.1 The resulting product was first published in 20012,3 and has successfully served as the common source document for all EM organizations. One of its strengths is incorporating the reality that EM is a specialty driven by symptoms not diagnoses, requiring simultaneous therapeutic and diagnostic interventions. The task force that developed the EM Model recommended that a new task force, composed of representatives from all six organizations, be formed every 2 years to assess the success of the document in accomplishing its objective of supporting the ongoing development of the specialty of EM, to consider alterations to the EM Model suggested by the collaborating organizations, and to recommend changes to the six sponsoring organizations. The initial 2-year review occurred in 2003 with representatives from each of the six organizations suggesting changes and reporting how their respective organizations had used the document. This initial 2-year update was published in Annals of Emergency Medicine and Academic Emergency Medicine in 2005.4,5 Minor changes were agreed upon and incorporated into the EM Model at that time. In addition, the task force recommended continuing a two year review of the EM Model. The six organizations convened again in 2005, and a review similar to that conducted in 2003 occurred. This 2005 revision was published in Annals of Emergency Medicine and Academic Emergency Medicine in 2006.6,7 The next regular review of the EM Model occurred in 2007. This article provides a brief review of the original EM Model, a listing of the conditions and components which include the changes made before and during the 2005 review, a summary of the changes made to it as a result of the 2007 review conducted by the current task force, and an update on current uses of the EM Model by the six collaborating EM organizations. The EM Model is a three-dimensional description of EM clinical practice. The three dimensions are patient acuity, physician tasks, and the listing of conditions and components. All of these dimensions are interrelated and employed concurrently by a physician when providing patient care. The EM physician’s initial approach is determined by the acuity of the patient’s presentation. While assessing the patient, the physician completes a series of tasks collecting information. Through this process, the physician is able to select the most likely etiology of the patient’s problem from the listing of the conditions and components. Through continued application of all three components, the physician is able to arrive at the most probable diagnosis and subsequently implement a treatment plan for the patient. Hence, the three dimensions of the EM Model are interrelated and applied concurrently in the practice of EM. The three dimensions as revised in 2005 are included in Tables 1–4 (Table 4 available as Supporting Information). The Accreditation Council for Graduate Medical Education (ACGME) is implementing the ACGME Outcome Project to assure that physicians are appropriately trained in the knowledge and skills of their specialties. The ACGME derived six general (core) competencies thought to be essential for any practicing physician: patient care, medical knowledge, practice-based learning and improvement, interpersonal skills, professionalism, and systems-based practice. The six general competencies are an integral part of the practice of EM and are embedded into the EM Model. To incorporate these competencies into the specialty of EM, an Emergency Medicine Competency Task Force demonstrated how these competencies are integrated into the EM Model.8,9 The EM Model is designed for use as the core document for the specialty. It will provide the foundation for developing medical school and residency curricula, certification examination specifications, continuing education objectives, research agendas, residency program review requirements, and other documents necessary for the functional operation of the specialty. In conjunction with the EM Model, these six general competencies construct a framework for evaluation of physician performance and curriculum design to further refine and improve the education and training of competent emergency physicians. The six competencies and the EM Model also form the core of ABEM’s Maintenance of Certification program, Emergency Medicine Continuous Certification (EMCC). For further information on the EMCC program see ABEM’s website, http://www.abem.org/. The 2007 EM Model Review Task Force met to consider changes based on feedback received from the six collaborating organizations. Each organization was asked to comment on how it was using the EM Model and to recommend changes in the document that would address its perceived deficiencies. The changes that were recommended by the task force and accepted by the six organizations are listed in Table 5. ABEM uses the EM Model to define its test and examination specifications. Each question or structured case used in any ABEM examination is referenced to the EM Model. Every test and examination that ABEM develops is based on a blueprint derived directly from the EM Model. It also uses the Conditions and Components section to structure the Lifelong Learning and Self-Assessment component of its EMCC program. ACEP uses the EM Model primarily as the basis for its educational activities. In addition, the ACEP Academic Affairs Committee used the EM Model to survey EM residency program directors and recent residency graduates to identify curricula gaps and educational needs. This information has been used to develop a comprehensive list of Web-based educational resources that can be incorporated into residency curricula. The most original application of the EM Model is the above-referenced demonstration that the six ACGME core competencies are embedded in the EM Model. The integration of the competencies in the EM Model forms a major tool for EM program faculty to use when integrating the competencies into the training and evaluation of their residents. In summary, the EM Model is accomplishing the purposes for which it was developed. The 2007 review of the document resulted in the incorporation of only minor changes and clarifications. Several EM organizations are using the EM Model to support the ongoing development of the specialty of EM. The complete updated 2007 EM Model can be found on the websites of each of the six collaborating organizations. Data Supplement Table 4. Listing of conditions and components, procedures and skills, and other components of the practice of emergency medicine (PDF file). Please note: Wiley Periodicals Inc. are not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.