Emergency medicine clerkship curriculum in a high-income developing country: methods for development and application

Each medical student must be competent in basic acute care medicine [1, 2]. Emergency medicine clerkships provide unique experiences to improve students’ confidence in managing acute care situations [3]. Although providing and teaching acute care is as old as medicine itself, the earliest formal undergraduate curriculum recommendations by Society of Teachers of Emergency Medicine stating the minimum standards in undergraduate emergency medicine (EM) education were made in the 1980s [4]. Since then, various organizations from developed countries have published undergraduate EM curricula [5–8].

The conception of curricula, evolved from a syllabus-like, content-based perspective to ones defining various components including purposes, experiences, methods, and evaluation [9, 10]. The aforementioned organizations have limited their recommendations covering the content of a curriculum, but excluded teaching and learning (TL) methods, assessment, and evaluation. The efforts to specify the minimum standards of undergraduate EM curriculums are short in these aspects.

The development process of our EM clerkship started at June 2013 and the current form of the curriculum was developed at the end of the academic year of 2016–2017. It was a 4-year continuous development process. We acknowledge that the above published recommendations discuss deeply the outcomes and the content of a standardized undergraduate EM curriculum. This article provides details of an emergency medicine clerkship as an example for developing and developed countries having immature undergraduate emergency medicine clerkship curriculum. In this communication, we aim to share our example of EM clerkship curriculum including TL methods, assessment, and evaluation, and finally discuss the theoretical knowledge behind our practice so as to help other colleagues in other countries to have a clear map for developing their own curricula.

We presented the UAEU undergraduate EM curriculum to serve as a model for clerkship directors in developing countries. Table 1, Additional file 1: Appendices 1–4 provide the details of schedule, stakeholders’ feedbacks, educational activities, assessments, and online feedbacks of tutors for case discussions, respectively.

Many valuable frameworks and resources regarding content and learning outcomes are available [7, 8, 11]. These frameworks are syllabus-like, excluding TL methods, assessment, and evaluation. Moreover, examples of a structured EM curricula are few in developing countries [26]. Although recommended topics and learning outcomes are applicable to different settings, a local learning needs assessment covering all stakeholders should be conducted to modify content according to context [27, 28].

Our outcome-based undergraduate EM curriculum is a blend of multiple educational trends and e-learning. In outcome-based education, course outcomes guide all curriculum plans and processes [29]. The content, its organization, educational environment, teaching and learning methods, assessments, and curriculum evaluation processes are defined under the guidance of the ILOs. Outcome-based education encourages shared responsibility for learning among the teachers and the students [29]. Teachers should assure that guidance, TL methods, and resources are sufficient to achieve the learning outcomes. In contrast, students are responsible for giving their effort to reach those outcomes.

Today, medical teachers are aware of the limited positive impact of large group lectures on deep learning [30]. Interactivity supports questioning and engagement during face-to-face sessions [30]. Interactive case discussions enhance learning by making connection between knowledge-based class activities and the real clinical environment [31]. Case discussions encourage self-regulated learning [32]. It also identifies the gaps in knowledge or skills [33] and gives the tutor a chance to provide feedback. Thus, in our curriculum, case discussions are in the center of flipped classroom and TBL sessions.

The flipped classroom is a blended approach in which learners prepare themselves for the topic independently in a learner-paced manner before the class with given videos and online resources [32, 34, 35]. Classroom time is dedicated to knowledge application, simulation, case-based learning [34]. This process also facilitates student-centered learning which allows the students to determine their specific learning goals [13]. Student-centered education encourages students explore the solutions without a complete dependence on a tutor or instructor learning and promotes life-long learning [36]. Although EM literature does not show a difference in gained knowledge [37], students and teachers prefer flipped classroom over traditional lecturing because of interactivity, discussions, active participation, and synthesized knowledge [35].

TBL is an interactive small group activity needing less resources which is directed by a teacher [38–40]. It has certain advantages over passive, didactic, lecture-based learning. It promotes critical thinking, problem-solving, team building and communication skills [41, 42]. Although many studies showed knowledge increases via TBL, Fatmi et al.’s systematic review highlighted the need for further studies regarding its effectiveness [43]. Unlike other established fields [43, 44], TBL in EM education is still developing [45, 46]. Our recent experience between 2015 and 2017 has shown that TBL improved knowledge-based performance both in clerkship and medical school exit exams with better long-term knowledge retention (unpublished submitted data, Cevik AA et al.).

E-learning creates a compelling learning environment which expands students’ thinking processes and knowledge [47]. It is flexible regarding pace, place, and mode, and it enables personalized learning [48]. It supports both synchronous and asynchronous learning [48]. e-Portfolio provides real-time data regarding students’ strengths and weaknesses at both individual- and group-level [48, 49]. It catalyzes data analysis. Another advantage of online learning environment in our curriculum is to provide continuous feedback to students. One of the significant advantages of using e-learning tools in our clerkship was guiding the students with continuous feedback regarding their e-Portfolio logs to achieve the curriculum recommendations [50]. Medical students highly valued the use of e-learning platforms even in the clinical skills education [51].

Technology is a tool to reach desired learning outcomes, and without adequate motivation, students may not completely engage with it [52]. Therefore, faculty members/tutors should generate interest and continuously monitor and support learning processes [52]. Some authorities state that technology makes learning more relevant, and thus, motivates students [53, 54]. Students express that technology enriches their learning experience, and they prefer blended learning over the face-to-face model [55]. Today, there is adequate evidence to show that students are motivated by technology-enhanced learning methods [52].

Yeung et al. reported that students appreciated receiving multiple feedback and evaluation from their tutors and supervisors during the EM clerkship [56]. Feedback is one of the major components of our curriculum. Without a goal or outcome-directed formative feedback, students’ achievements will be minimal [57]. Immediate feedback is powerful and efficient at correcting problems in knowledge and skills [58].

Assessment drives learning [59]. There are six different types of assessments in our curriculum (Additional file 1: Appendix 3). Although summative assessments have some value in feedback, formative assessment aims to provide useful feedback on student strengths and weaknesses concerning the ILOs [60]. Formative assessments motivate students, and motivation increases learning [61]. The main advantage of implementing multiple formative assessments is to measure student’s level of accomplishment and guide their learning by frequent feedback [62]. Clerkship directors should ensure that the ILOs, TL activities, and the assessment are aligned [63, 64].

We have to acknowledge that our curriculum has certain shortages. The process is time and resource consuming. Because of faculty shortage and rapid turnover rate of attending physicians and adjunct faculty members, application of the curriculum needs close clerkship director control. The extreme variations in attending physicians’ scoring and time constraints may hinder the sufficient number of assessments [65]. This has forced us to remove some proven validated bedside assessments such as Mini-Clinical Evaluation Exercise. Some authors claim that the required number of stations for reliable OSCEs is 16 [66]. However, the number of available examiners limits our number of stations to be only eight. On average, our students reach the required number of clinical cases and procedures. However, their distribution of exposure is still non-homogenous [25]. The high number of trainees and residents at different levels compete with our students on their learning opportunities. Accordingly, students have difficulty in reaching the planned targets even though they rotate in all available teaching hospitals in our city. This makes us think that four weeks may be a short period for medical students to grasp all needed skills to manage acute care medicine in our setting. In our format, i-RAT and t-RAT require the use of students’ mobile devices. This increases the risk of copying the questions. Therefore, a considerable part of the clerkship director’s effort goes into creating new questions for each group to be used in TBL assessments. We use OneNote very actively. However, it does not have analytical power. Thus, we are not able to effectively judge the extent of students’ involvement in our virtual learning environment.

In this manuscript, we gave one example of an application of EM curriculum in a high-income developing country. We highlighted the steps that EM clerkship curriculum developers and directors should consider. We think that our reported curriculum which has details of multiple options of teaching-learning methods and assessments will guide other colleagues in developing and developed countries having immature undergraduate emergency medicine clerkship curriculum to develop or improve their own. The application of these recommendations will vary in different settings depending on resources. However, the main message is that it is important to create the curriculum content having learning outcomes relevant to the local context, and then align the TL activities, assessments, and evaluations to be in harmony. The importance and necessity of EM training in medical schools is recognized, and thus, EM training is a critical component of medical education programs [2]. Therefore, EM clerkship curricula should not only include listed topics and learning outcomes, but also all required components of a modern curriculum including TL methods, assessments, and evaluation process.