EDUCATION/SPECIAL CONTRIBUTION

Report of the Task Force on National Fourth Year Medical

Student Emergency Medicine Curriculum Guide
Task Force on National Fourth
Year Medical Student
Emergency Medicine
Curriculum Guide*:
David E. Manthey, MD, Chair
Wendy C. Coates, MD, Vice-Chair
Douglas S. Ander, MD
Felix K. Ankel, MD
Howard Blumstein, MD
Theodore A. Christopher, MD
James M. Courtney, DO
Glenn C. Hamilton, MD
Eve K. Kaiyala, MD
Kevin Rodgers, MD
Aaron B. Schneir, MD
Stephen H. Thomas, MD

This manuscript reports recommendations of the national fourth year medical student emergency
medicine curriculum guide task force. This task force was convened by 6 major emergency medicine
organizations to develop a standardized curriculum for fourth year medical students. The structure of
the curriculum is based on clerkship curricula from other specialties such as internal medicine and
pediatrics. The report contains a historical context, global and targeted needs assessment, goals and
objectives, recommended educational strategies, implementation guidelines, and suggestions on
feedback and evaluation.

0196-0644/$-see front matter

Copyright ª 2006 by the American College of Emergency Physicians.
doi:10.1016/j.annemergmed.2005.09.002

[Ann Emerg Med. 2006;47:E1-E7.]
INTRODUCTION
In 1995, the Macy Foundation Report stated: ‘‘All students
who graduate from medical school should be capable of handling
emergency situations.’’1 Review of the literature shows that the
Society for Academic Emergency Medicine (SAEM) have
developed and published curricula in 1997 and 1998 that could
be instituted throughout the various years of medical school.2,3 In
2002, the Liaison Committee on Medical Education report
specifically mentioned emergency medicine for the first time,
noting that ‘‘educational opportunities must be available in
multidisciplinary content areas, such as emergency medicine and
geriatrics..’’4,5 The need for an organized national curriculum is
even more evident because the number of required emergency
*All members are listed in the Appendix.
medicine clerkships has steadily increased to 35% of medical
schools.
A task force was convened by 6 major emergency medicine
organizations (American Academy of Emergency Medicine,
American College of Emergency Physicians, Association of
Academic Chairs in Emergency Medicine, Council of Residency
Directors, Emergency Medicine Residents’ Association, and
SAEM) in 2003 to develop a standardized curriculum in
emergency medicine. This emergency medicine student
curriculum guide was developed with the purpose of combining
and updating the earlier versions into a single uniform
curriculum. This new curriculum will also address additional
aspects of curricular design, including feedback, evaluation, and
implementation. The most current Liaison Committee on
Medical Education requirements for clerkships are incorporated
into this curriculum. This version identifies areas of medical
student education that are either unique to or suitably covered
by emergency physicians to aid medical schools in developing a

Volume 47 Annals of Emergency Medicine E1

Fourth Year Medical Student Emergency Medicine Curriculum Guide Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide
Table 1. Core competency-based course objectives.
Core Competency Course Objective
Patient care Obtain an accurate history and physical
examination focused on key problems
Recognize immediate life-threatening
illnesses
Patient management skills
Develop an evaluation and treatment
plan
Monitor the response to therapeutic
interventions
Make proper disposition and follow-up
plans for the patient
Procedural skills
Learn the indications and
contraindications for basic procedural
skills
Perform basic procedural skills
(Educational Core section)
Health promotion
Discuss preventable injuries and illnesses
Educate patients and insure
comprehension of their outpatient
treatment plan
Medical knowledge Develop the skills to evaluate an
undifferentiated patient
Development of a differential diagnosis
Hierarchy based on the initial patient
presentation
Be aware of worst-case diagnoses
Develop management plan for the
evaluation of the patient
Interpret the results of common
diagnostic procedures and tests
Learn key concepts of
the topics within the educational core
Practice-based learning Effectively use available information
technology to solve patient care problems,
improve knowledge base, develop case
presentations
Interpersonal and Humanistic qualities
communication skills Effectively communicate patients and
family members
Show compassion and nonjudgmental
approach to all patients
Work in a collegial manner within a
health care team
Presentation skills
Present cases in a complete, concise,
and orderly pattern
Clearly delineate primary problems and
management plan
Complete documentation that is
accurate, well organized, and appropriate
for level of care provided
Professionalism Work ethic
Be conscientious, on time, and
responsible
Exhibit honesty and integrity in patient
care
Practice ethical decisionmaking
Professional behavior
E2 Annals of Emergency Medicine
Table 1 (continued).
Core Competency Course Objective
Exercise accountability
Maintain a professional appearance
Be sensitive to culture issues (age,
sex, culture, disability, etc)
System-based Make an appropriate referral from the ED
practice Understand the role of emergency
medicine in the community, including access
to care and its impact on patient care
Be aware of medication and treatment costs
comprehensive curriculum. The structure of the curriculum
was based on review of curricula of other specialties such as
the Clerkship Directors of Internal Medicine and the Council
of Medical Student Educators–Pediatrics.
The uniformity of a curriculum across medical schools
would make the education, evaluation, and testing of all
students in emergency medicine more comparable. This
approach was designed for fourth year rotations because these
students already have basic clinical skills, knowledge, and
experience from the uniform core third year clinical rotations.
Goals and Objectives
The emergency medicine curriculum guide objectives specify
student skills and behaviors that are central to care of an
emergency department (ED) patient and are appropriately
evaluated in the context of a fourth year emergency medicine
rotation (Table 1). The complexity of the tasks was selected to
correspond to the abilities of a fourth year student. These
objectives are based on previous curricula and Liaison
Committee on Medical Education directives for clerkship
objectives. Using the Accreditation Council for Graduate
Medical Education6 core competencies as a framework, we
developed the key learning goals for fourth year students
enrolled in an emergency medicine rotation. Use of the same
terminology helps ease the transition between undergraduate
and graduate education for the student and the educator.
These objectives can be taught and evaluated in various
settings to include clinical bedside teaching,7-13 standardized
patients,14-16 observed structured clinical evaluation,17 lectures,
problem-based learning groups,18,19 self-directed learning
materials, and simulations.20-23
Educational Core
In addition to the objectives of the emergency medicine
rotation, the educational core identifies the basic set of clinical
presentations, procedures, and educational topics that would be
covered or experienced during the clerkship. This core is
based on previously published curricula and consensus opinion.
There will be wide variability in how this educational core is
taught, reflecting the resources of each program.
Clinical experience. Clinical experience in the ED is the
foundation of all emergency medicine clerkships. The major
portion of the clerkship should involve medical students
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Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide Fourth Year Medical Student Emergency Medicine Curriculum Guide
primarily treating patients in the ED under qualified
supervision. Because of multiple factors, including the
unpredictable nature of emergency medicine, clinical experience
may be quite variable, even within a clerkship rotation.24
The Liaison Committee on Medical Education has
recommended that ‘‘the objectives for clinical education must
include quantified criteria for the types of patients (real or
simulated). needed for the objectives to be met.’’ Certain
presentations of ED patients that are common and to which all
fourth year medical students would be uniformly exposed
during their clinical experience based on a national curriculum
are listed below.2,25-29
1. Abdominal/pelvic pain
2. Alteration/loss of consciousness
3. Chest pain
4. Fracture
5. Gastrointestinal bleeding
6. Headache
7. Resuscitation
8. Shock
9. Shortness of breath
10. Vaginal bleeding
11. Wound care
This list is not meant to identify the only types of patients a
student will encounter or negate the importance of many other
patient presentations. Recognizing the variation in clinical
venues between various EDs, this task force believes the
quantification of the presentations on this list should be left to
the individual institutions.
Procedures. Certain procedures to be taught under
appropriate supervision during the emergency medicine
rotation are listed below. Procedures were selected based on
clinical relevance, level of student training, and availability
within the ED.
1. ECG
2. Foley catheter placement
3. Interpretation of cardiac monitoring
4. Nasogastric tube placement
5. Peripheral intravenous access
6. Pulse oximeter
7. Splint application
8. Wound closure
9. Venipuncture
The procedures listed here are derived from previous
curricula, consensus opinion, and informal evaluation of
procedures currently performed on rotations. In recognition of
the variation of what procedures might be available on clinical
shifts, the use of cadaver lab, mannequins, direct observation,
videotape presentations, and simulators is encouraged.19-23
Students may have already developed competency in a given
procedure during an earlier rotation.
Essential topics. Clinical experience cannot provide a student
with every aspect of the curriculum, nor can one guarantee what
clinical presentations a student will encounter. Therefore, a
core knowledge base relevant to emergency medicine topics
Volume 47
should also be taught. This list of essential topics is based on
previously published curricula, the model curriculum for
emergency medicine residencies, and consensus opinion. The
topics are primarily organized by symptom complex or
presenting complaint and are listed in Table 2.
Although specific diseases are listed, a symptom-oriented
approach to instruction is recommended. The rationale behind
this approach is to emphasize the evaluation and treatment of
patients with undifferentiated disease processes, which is
fundamental to the practice of emergency medicine.30
We suggest that relevant epidemiology, pathophysiology,
medical history and physical examination findings, diagnostic
and therapeutic interventions, and disposition be addressed for
each symptom complex or disease process.
The various educational venues used to teach these topics
and procedures should ideally be complementary and may
include lectures, bedside teaching, self-study materials, medical
student-generated presentations, simulated encounters, direct
observation, and laboratory workshops.31
Feedback
The Liaison Committee on Medical Education has specified
that ‘‘each student should be evaluated early enough during a unit
of study to allow time for remediation.’’ Feedback is an
objective appraisal of performance that identifies potential areas
of improvement so that the student can progress in his or her
development.32 Distinct from evaluation, feedback presents
information, not judgment, and is timed to allow for the student
to improve. In the process of giving feedback to students,
emergency medicine teachers should be viewed as student allies.33
Identifiable goals and objectives should be given to the student
during an orientation process at the beginning of the clerkship and
should serve as the foundation for feedback, formal testing, and
evaluation.7,32,34 Feedback, when used to alter an undesirable
behavior, should be given in the form of constructive criticism
with alternative methods of addressing the dilemma. Feedback
should also be used to reinforce those desirable traits and
behaviors. A resource on feedback with students is available at
SAEM Medical Student Educator’s Handbook, available online
at http://www.saem.org/download/Hand-4.pdf.
There are 3 ideal times for student feedback. ‘‘Brief’’
feedback is spontaneous and occurs at the point of contact.
A faculty member may give brief feedback when observing a
student physical examination on a patient or performance of
a procedure or when monitoring a student’s presentation of a
patient’s medical history and examination in the clinical or
didactic venue.
‘‘Formal’’ feedback is provided when a period, usually 5 to
10 minutes, is set aside to deliver feedback to the student.
Formal feedback may relate to the management of a particularly
difficult or confusing case, to a medical mistake, or to a
behavioral issue. Formal feedback is best given at the end of a
shift. Ideally, this feedback should be given to students daily.
The more frequent the feedback and the closer to the event, the
more effective it is for the student. Students should be
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Fourth Year Medical Student Emergency Medicine Curriculum Guide Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide

Table 2. Core educational topics. Table 2 (continued).

Presenting Conditions (Approach to ...) Presenting Conditions (Approach to ...)
Approach to ... Specific Disease Entities Approach to ... Specific Disease Entities
Abdominal/ Aortic aneurysm Traumatic injuries Abdomen (bowel, hepatic, splenic injuries)
pelvic pain Appendicitis Chest (hemothorax, pneumothorax, tension
Bowel obstruction pneumothorax)
Cholelithiasis/cholecystitis Extremities
Diverticulitis Dislocations
Ectopic pregnancy Fractures
Ovarian torsion Splinting
Nephrolithiasis Head injuries (epi-/subdural hematomas)
Testicular torsion Neck/spine (cervical spine fractures, spinal
Alteration/loss of Hypoglycemia cord damage)
consciousness Seizure Pediatric nonaccidental trauma/domestic
Syncope violence
Chest pain Acute coronary syndromes Vaginal bleeding Abortion (threatened/ complete/incomplete/
Aortic dissection inevitable)
Pneumothorax Ectopic pregnancy
Pulmonary embolism Placenta previa
Environmental Burns (chemical, thermal) Placental abruption
exposures Envenomations (hymenoptera, Latrodectus, Weakness and Cerebrovascular accident (embolic,
Crotalus) dizziness hemorrhagic, thrombotic)
Hypothermia/hyperthermia Vertigo (benign positional vertigo, cerebellar
Eye pain, vision Acute angle closure glaucoma hemorrhage)
change Trauma Wound care Irrigation
Retinal detachment Local anesthesia
Gastrointestinal Upper (peptic ulcer disease, variceal) Primary closure
bleeding Lower (diverticulosis, hemorrhoids, Tetanus prophylaxis
malignancy)
Headache Mass lesions
Meningitis
encouraged to ask for specific comments on their performance
Migraine and areas to improve at the end of each shift.
Subarachnoid hemorrhage ‘‘Major’’ feedback consists of scheduled sessions midway
Poisoning/overdose Anion gap metabolic acidosis through the clerkship. These sessions should always be held in
Decontamination (activated charcoal) private and typically last for 15 to 30 minutes. The student knows
Specific poisonings/overdoses
Acetaminophen
ahead of time when his or her major feedback session will
Carbon monoxide occur and is able to reflect on and assess his or her performance
Opioids before feedback is given. This major feedback session is critical
Salicylates so that the student can be given areas to work on and remediate
Tricyclic antidepressants during the remainder of the rotation instead of discovering at
Toxic alcohols (ethylene glycol, methanol)
Psychiatric Psychosis
the end of the clerkship that there were deficiencies. It is also an
Substance abuse excellent time to monitor the progress of a student’s attainment
Suicidal ideation or attempt of an appropriate number of clinical procedures and skills,
Resuscitation Basic airway management which may be a condition on which graduation depends.
Basic airway maneuvers
Airway adjuncts Evaluation
Bag-valve-mask ventilation The Liaison Committee on Medical Education also specifies
First minute of a code
that ‘‘the directors of all courses and clerkships must design and
Cardiopulmonary resuscitation
Dysrhythmia identification/treatment implement a system of formative and summative evaluation
Shock Anaphylactic of student achievement in each course and clerkship.’’ The
Obstructive (pulmonary embolism, pericardial evaluation of students should be designed to assess the
tamponade) performance of the student based on the predefined learning
Cardiogenic
Hypovolemic
objectives. Core evaluation methods are discussed in current
Septic literature available to the clerkship directors.35,36
Shortness of breath Airway obstruction Summative and formative evaluation. Evaluations of students
Asthma/chronic obstructive pulmonary disease should be structured and contain summative and formative
Heart failure evaluation processes. Summative evaluation involves making
Pneumonia
judgments about the student’s concrete achievements during the
Pulmonary embolism
rotation; it is the mechanism by which students are

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Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide Fourth Year Medical Student Emergency Medicine Curriculum Guide
‘‘accountable’’ for what they have learned during the rotation.
Summative evaluation is primarily a retrospective process in
which students’ accomplishments and habits are documented.
Formative evaluation focuses on identifying student
strengths (for subsequent amplification) and weaknesses (for
remediation). Formative evaluation is primarily a prospective
process in which students’ strong and weak points are assessed
with an eye toward improvement in future evaluations.
Optimally applied, formative evaluation helps students develop
good habits. Many types of formative evaluation can also be
used as aids for summative evaluation, and vice versa. For
example, testing can be used, at least in part, for both types
of evaluation.
The final evaluation is summative but may include formative
comments. The summative evaluation should clearly define
the student’s abilities with respect to the identified objectives
based on their performance during the rotation. Any
improvements made during the clerkship, especially on those
items identified at the ‘‘major’’ feedback session, should be
noted. The formative evaluation should provide the students
with their strengths, areas of improvement, examples of
deficiencies, and a plan for improvement.
Types of Evaluation
Although there are many types of evaluations, each with its
own values, we outline evaluations that are practical for all
rotations. Evaluation techniques beyond these are encouraged
based on the abilities and resources of the rotation.
Direct observation. Direct observation of a student during
history taking, physical examination, or procedures in the
clinical setting allows evaluation of a student’s ability based on
prespecified performance-based criteria.37-39 Interpatient
variability in clinical problems and a patient’s ability to be
interviewed are 2 potential confounders to this method of
evaluation. Resources available include the evaluation chapter in
the SAEM Medical Student Educators’ Handbook, available
online at http://www.saem.org/download/Hand-2.pdf.
Shift evaluation. Ideally, an evaluation in the clinical
setting can be done after every shift, if it is feasible.40
Evaluation of the student’s history and physical and
presentation techniques may occur during the oral presentation.
With direct questioning, additional information on the
student’s ability of investigatory thinking, application of basic
science knowledge, and the use of evidence-based medicine
to solve clinical problems may be evaluated. The student may
also be evaluated on his or her ability to define differential
diagnoses and develop treatment and evaluation plans.
Professionalism and the ability to communicate during
interactions with family, consultants, and coworkers can all be
assessed during this time.41
Examinations. Examinations (written or oral) can be
incorporated into the evaluation of the student’s knowledge
base and should correlate with the educational core topics.
A national testing database would aid educators in developing
a practice and final test. Ideally, the examination should be
Volume 47
studied by various statistical tests to ensure the test questions’
reliability, level of difficulty, and discriminatory power.
Objective testing must be supplemented by other evaluation
mechanisms, and the students should understand that the
educational goal is not short term retention of factual
knowledge. An examination should be used as part of a system
that fosters self-initiated learning by the student.
Procedural evaluations. Evaluation of procedural skills can
be measured against a checklist of essential actions during
direct observation of clinical work or during procedural
workshops. Although students should keep logbooks of
procedures performed, these are insufficient to evaluate the
technique of the student.
Format of final evaluation. The format of the final evaluation
is most often determined institutionally. However, in line with
Liaison Committee on Medical Education requirements, the
evaluation must include narrative descriptions of student
performance, including noncognitive achievements.5 This
evaluation should be based on faculty-student interactions
during the course.
Evaluation of the faculty and clerkship. All students
completing the emergency medicine clerkship must have the
opportunity to give feedback about their educational experience,
including individual faculty and the educational program.5
Students will feel most comfortable providing anonymous
feedback about their teachers and the clerkship at the end of the
rotation. Results may be useful for individual faculty
development and promotion, for identification of institutional
problems, and to provide evidence for resource allocation from
the medical school.
Implementation plan
Recognizing that resources and constraints vary by individual
institution, this curriculum is sufficiently broad based to allow
for individualization that conforms to the goals and resources of
the medical school and specific clerkship. It is suggested that
each clerkship director have the ability to mold the curriculum
to the strengths of the department and desires of the medical
school while remaining within a common framework that
allows for a uniform education of medical students in our
specialty. The following are based on available literature when
possible but also reflect the experience of the authors as
clerkship directors.
Prerequisites for clinical sites.42 The clerkship director should be
available to receive feedback from medical students for correcting
any identified inadequacies. The clerkship director would also
provide a summary evaluation at the end of the rotation. Ideally,
there would be an identified ‘‘site director’’ at each clinical location,
responsible for overseeing the education and well-being of the
students. The site director or clerkship director would ensure that
scheduling of student shifts conforms to standard duty hours if
required by the individual medical school.
Other desirable institutional features of a clinical site include
having adequate, up-to-date equipment, including computer or
library resources, as well as ensuring a safe environment.
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Fourth Year Medical Student Emergency Medicine Curriculum Guide Task Force on National Fourth Year Medical Student Emergency Medicine Curriculum Guide
Faculty members at a clinical site should be board certified
or residency trained in emergency medicine and should be
familiar with the course objectives. Faculty members should be
willing to make a consistent commitment to provide teaching and
formative evaluation during each shift. The faculty should be
dedicated to making certain that the student enjoys a broad-based
clinical experience that focuses on education, not service.43,44
Clinical experience. It is essential that the clerkship provide an
adequate clinical experience.45 The student should have the
opportunity to be involved with the aforementioned patient
presentations and procedures under faculty or upper-year-
resident supervision. Clerkship and site directors should use logs
to monitor the students’ experiences to include chief complaint,
final diagnosis, and procedures.
Based on these logs and required clinical experiences, the
clerkship may consider using scripted patient scenarios, high
fidelity simulation laboratories, and procedural models to
supplement clinical contact.
Didactic experience. Didactic opportunities should be
substantially similar at all sites. Goals and objectives, as well as
the educational core, should be maintained by the course
director and disseminated to site directors and faculty.
Optimally, didactic opportunities should be offered by qualified
emergency medicine faculty or by emergency medicine residents
with adequate supervision. Course directors may wish to hold
didactic opportunities at a single, central site in order to ensure
consistency of learning opportunities among students.
Regular feedback from students should be sought by the
course director and reviewed to ensure quality. The course
director should provide feedback to faculty and the academic
chair about opportunities for improvement.
Future directions
A cohesive network of educators can be formed to provide
continuous quality improvement of this document and the
education of medical students within the specialty of emergency
medicine. A repository of educational innovations can be
developed and shared among programs. Evaluation instruments
should be developed and implemented that will help educators
in assess competency within the recommended curriculum.
A national test can be developed based on the uniformity of
the educational curriculum among various clerkships.
Conclusion
A collaboration of medical education experts from the
major emergency medicine organizations has produced this
emergency medicine curriculum guide that proposes uniform
standards for the enrichment and advancement of the
education of medical students. This document has been
endorsed by all 6 of the participating emergency medicine
organizations. It should prove useful to clerkship directors,
emergency medicine faculty, and medical education deans to
plan or redesign a comprehensive program in emergency
medicine that addresses goals and objectives, core educational
topics, and feedback and evaluation.
E6 Annals of Emergency Medicine
Supervising editor: Donald M. Yealy, MD
Funding and support: The American College of Emergency
Physicians provided $300 for copyediting services. There is no
financial interest of the authors in this product. The authors
report this study did not receive any outside funding or support.
Publication dates: Received for publication May 12, 2005.
Revision received August 31, 2005. Accepted for publication
September 2, 2005.
Address for reprints: David E. Manthey, MD, Department of
Emergency Medicine, 4th Floor Watlington Hall, Wake Forest
University School of Medicine, Medical Center Boulevard,
Winston-Salem, NC 27157-1089; 336-716-4629, fax 336-716-
5438; E-mail Dmanthey@wfubmc.edu.
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Appendix. Task Force on National Fourth Year Medical Student
Emergency Medicine Curriculum Guide
David E. Manthey, MD, Chair, and Howard Blumstein,
MD, Department of Emergency Medicine, Wake Forest
University School of Medicine, Winston-Salem, NC; Wendy C.
Coates, MD, Department of Emergency Medicine, Harbor
UCLA Medical Center, Torrance, CA; Douglas S. Ander, MD,
Department of Emergency Medicine, Emory University School
of Medicine, Atlanta, GA; Felix K. Ankel, MD, Department of
Emergency Medicine, Regions Hospital, Emergency
Department, St. Paul, MN; Theodore A. Christopher, MD,
Department of Emergency Medicine, Thomas Jefferson
University Hospital, Philadelphia, PA; James M. Courtney,
DO, Department of Emergency Medicine, University of
Massachusetts Medical Center, Worcester, MA; Glenn C.
Hamilton, MD, Department of Emergency Medicine, Cox
Heart Institute, Kettering, OH; Eve K. Kaiyala, MD,
Department of Emergency Medicine, Valley Medical Center,
Renton, WA; Kevin Rodgers, MD, Department of Emergency
Medicine, Indiana University, Indianapolis, IN; Aaron B.
Schneir, MD, Department of Emergency Medicine, UCSD
Medical Center, San Diego, CA; Stephen H. Thomas, MD,
Department of Emergency Medicine, Massachusetts General
Hospital, Boston, MA.
These members represented the following organizations:
American Academy of Emergency Medicine, American
College of Emergency Physicians, Association of Academic
Chairs in Emergency Medicine, Council of Residency
Directors–Emergency Medicine, Emergency Medicine
Residents’ Association, and the Society of Academic Emergency
Medicine.
The task force received letters of endorsement from all 6 of
the organizations.
Annals of Emergency Medicine E7