A Stepping Stone to Standardization

   The declaration last year of EMS as an officially recognized medical subspecialty-so decreed by the American Board of Emergency Medicine (ABEM), one of 24 medical specialty boards under the American Board of Medical Specialties (ABMS)-was met with hosannas across the prehospital community. But for the programs actually training the medical directors of tomorrow, now comes the hard part.

   Among the ramifications of the long-sought decision, EMS fellowship programs could face hurdles to meet new requirements for accreditation by the Accreditation Council for Graduate Medical Education (ACGME).

Background

   ABMS' member boards represent 145 recognized medical specialties and subspecialties. Under ABEM, EMS joins medical toxicology, pediatric emergency medicine, sports medicine, undersea/hyperbaric medicine, and hospice/palliative medicine.

   "Subspecialty certification is one of the stepping stones toward standardizing EMS care in the United States," says Jane Brice, MD, MPH, an associate professor of emergency medicine and director of the EMS fellowship program at the University of North Carolina, who led the team writing the new fellowship curriculum.

   "When you standardize the training and knowledge base EMS medical directors bring to their systems, you create a foundation on which to build. Going forward, EMS medical directors who are board certified in EMS will have had the same training, based on a standardized curriculum, and will have all passed the same test, which guarantees a foundation of knowledge. That will lead to more cohesiveness and interoperability between systems."

   ABEM will develop and administer the certification exam for graduates of accredited fellowship programs, which is expected to be ready in 2013. In the meantime, leaders of the EMS subspecialty effort have been working out exactly what those fellows will learn.

   EMS already had a fellowship curriculum and supporting core content, but that was developed in 1994 and thus outdated. Both components needed revamping to be more clinical and current.

   A team led by Johns Hopkins' Michael Millin, MD, rewrote the core content, and once ABEM signed off on that, Brice's group set the curriculum. The format they utilized mirrored the four volumes of the NAEMSP's Emergency Medical Services: Clinical Practice and System Oversight text: clinical aspects of prehospital medicine; medical oversight of EMS; quality management and research; and special operations (see Figure1).

   In delivering that curriculum, accredited fellowship programs will have to meet requirements of the ACGME. And while those are still officially under development, an early draft version provides an idea of what they might entail.

   They describe desired fellowship outcomes and set minimum requirements for fellows, program directors and faculty. Notably, they require of fellowship institutions instruction in a broad range of areas pertinent to EMS-not only expected fields like resuscitation, critical care, trauma and infectious disease, but also areas like air medical services, psychiatry and ophthalmology, which some fellowship programs may not currently cover.

   "Our fellowship programs are currently homegrown, so they build on the strength of their institution," says Brice. "For instance, your institution may not have an aeromedical program, so you're not able to provide your fellow with training in aeromedical systems.

   "In setting out what an EMS fellow needs to know," Brice continues, "the EMS fellowship curriculum will require that fellowships not necessarily develop those expertises or specialties, but at least create agreements with other institutions that can provide fellows with that information, so that every fellow graduating from a fellowship program has the same foundation of knowledge."