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JAOA/AACOM Medical Education  |   June 2018
Use of a Clinical Pathologic Conference to Demonstrate Residents’ ACGME Emergency Medicine Milestones, Aid in Faculty Development, and Increase Academic Output
Author Notes
  • From the Lehigh Valley Health Network in Allentown, Pennsylvania, and the University of South Florida at Morsani College of Medicine in Tampa. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Kathleen Kane, MD, Lehigh Valley Health Network, EM Residency Suite, 5th Fl, 2545 Schoenersville Rd, Bethlehem, PA 18017-7300. Email: kathleen_e.kane@lvhn.org
     
Article Information
Medical Education / Graduate Medical Education
JAOA/AACOM Medical Education   |   June 2018
Use of a Clinical Pathologic Conference to Demonstrate Residents’ ACGME Emergency Medicine Milestones, Aid in Faculty Development, and Increase Academic Output
The Journal of the American Osteopathic Association, June 2018, Vol. 118, 410-415. doi:10.7556/jaoa.2018.085
The Journal of the American Osteopathic Association, June 2018, Vol. 118, 410-415. doi:10.7556/jaoa.2018.085
Abstract

The Emergency Medicine Milestones Project, developed by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Emergency Medicine, includes competence targets for residents to attain and, ultimately, to exceed American Osteopathic Association and ACGME expectations for residents. The authors sought to use the clinical pathologic conference (CPC) format in their institutions’ Emergency Medicine Milestones Project to provide measurable residency academic and faculty development outcomes. The CPC is an event in which a resident presents an unknown case to a discussant in advance of a didactic session to demonstrate an organized approach and decision-making rationale to a differential diagnosis. Feedback forms included the assessment of resident discussants from the perspective of level-5 Milestone achievements in particular. Developing an internal CPC competition with a dedicated core faculty coordinator who provides skill development for both resident and faculty presentation has proven successful. Such a competition can document the level-5 achievements for senior residents, be a source of faculty development, and increase peer-reviewed academic output.

The clinical pathologic conference (CPC) is a presentation of an unknown case to a discussant in advance of a didactic session to demonstrate an organized approach to a differential diagnosis. In emergency medicine (EM), both osteopathic and allopathic professional societies hold annual CPC competitions using resident presenters and faculty discussants regionally and nationally.1 Cases presented need to be relevant to the specialty, solvable based on information typically available in a specialist encounter, and worthy of discussion.1 Key features include a logical discussion of the differential diagnosis and a clear rationale for the decision-making process. Both the case presentation and discussion require effective presentation skills. 
The Milestones Projects developed by the Accreditation Council for Graduate Medical Education's (ACGME) and specialty boards provide competence targets for residents in each specialty.2 The guidelines for the EM Milestones Project resulted from a joint effort by the American Board of Emergency Medicine and the ACGME. There are 23 Milestones, and with each milestone a resident or fellow may achieve a level 1 (skills expected of an incoming resident) through level 5 (skills that exceed expectations for graduation requirements, including higher-level cognition and the ability to recognize and avoid cognitive errors). 
In a CPC presentation, a resident has an opportunity to demonstrate skills relevant to Milestones 2, 3, 4, and 6.2 Milestone 2 describes the ability to obtain a focused history and physical examination. Milestone 3 involves the application of diagnostic study results to a patient encounter. Milestone 4 measures how a resident, who has collected all available data, reaches a diagnosis. Milestone 6 culminates the encounter by including patient reevaluation and diagnostic data to determine the ultimate diagnosis and treatment plan. 
Residents and faculty in osteopathic EM residency programs are required by both the ACGME and the American Osteopathic Association (AOA), in collaboration with the American College of Osteopathic Emergency Physicians, to engage in scholarly activity.3 The goals of this Milestones Project were to use the CPC format to develop residents’ clinical skills, as well as faculty development (presentation skills, scholarly activity), to provide data for EM residency Milestones (most notably level 5 achievements for senior residents and fellows) and to increase academic output by residents and faculty. In the present article, we describe the implementation of the EM Milestones Project and report outcomes with regard to milestone attainment, faculty development, and academic output. 
EM Milestones Project
This educational process-change project was determined to not be research by the institutional review board and was exempt from its oversight. It was conducted at a dually accredited AOA/ACGME residency program containing 13 residents/fellows per class (year 1 through year 4 [residents] and year 5 [fellows]). With the introduction of this Milestones Project in 2003, we hypothesized that year-4 residents serving as case discussants could demonstrate that they had attained level-5 performance in multiple Milestones. 
Curricular Design
An EM core faculty member was named the program's CPC coordinator and was responsible for collecting cases, assigning discussants, providing direction for each participant, coordinating senior faculty judges, and collating and returning specific feedback to each participant. The same CPC faculty coordinator and judges were used during both phases. The development of the CPC to be used as a measure of Milestone competency occurred during several months, including most of early 2013. This internal CPC was used to prepare for the annual statewide CPC competition. Also, presentation skills as outlined in the ACEP Teaching Fellowship, which is a longstanding 2-week course designed to help junior EM faculty members become better resident educators, were highlighted and distributed to participants prior to the internal CPC.4 
Phase 1: 2003-2013
Junior residents (years 1 and 2) were required to submit a case to the designated faculty CPC coordinator (Figure 1). Emergency department case submissions required full medical history and physical examination findings from an emergency department encounter, as well as deidentified laboratory, electrocardiography, and radiology imaging results. During a subsequent grand rounds, the annual internal CPC competition was held with the presenters (ie, junior residents) and discussants (ie, junior faculty, who critiqued the presenters’ case presentation). The junior residents competed against each other. The junior faculty members did not know the case in advance. This internal competition, usually held in the spring, is used to prepare for the statewide CPC competition, usually held in the fall. 
Figure 1.
Timeline for junior (year-1 and year-2) residents to choose and prepare cases for discussion during the internal annual clinical pathologic conference (CPC), which is used to demonstrate residents’ Accreditation Council for Graduate Medical Education emergency medicine (EM) Milestones, aid in faculty development, and increase academic output. Abbreviation: H&P, history and physical examination.
Figure 1.
Timeline for junior (year-1 and year-2) residents to choose and prepare cases for discussion during the internal annual clinical pathologic conference (CPC), which is used to demonstrate residents’ Accreditation Council for Graduate Medical Education emergency medicine (EM) Milestones, aid in faculty development, and increase academic output. Abbreviation: H&P, history and physical examination.
A feedback form was used by the CPC coordinator to assess the presentation skills of the resident case presenter and faculty discussant. The form focused on oral presentation skills. Resident presentation factors, such as time, slides, and quality of case, were judged using a Likert scale from 1 (best) to 6 (worst). Discussants were judged on “diagnosis considered” and “diagnosis made.” Using a Likert scale for 1 (best) to 6 (worst), discussants were also judged on the following skills: 
  • ■ ability to identify obscure, occult, or rare patient conditions based solely on historical and physical examination findings
  • ■ ability to discriminate between subtle or conflicting diagnostic results in the context of the patient presentation
  • ■ ability to use pattern recognition to identify discriminating features between similar patients and avoid premature closure of thought process
  • ■ ability to develop protocols to avoid potential complications of interventions and therapies
Internal competitions include 3 judges: 2 senior EM core faculty with additional training (eg, ACEP Teaching Fellowship) and a PhD educator. Feedback was summarized and returned to participants by the CPC coordinator; the EM program coordinator also filed this information in the residents’ portfolio. After the competition, the CPC coordinator worked with the highest-rated residents and faculty to refine their skills for presentation at external competitions. 
Phase 2: 2013-2016
Phase 2 was implemented to document level 5 Milestones for senior residents’ portfolios. For our 4-year EM residency program, year-4 residents and fellows were substituted for faculty to serve as discussants in the internal competition. (For shorter EM residency programs, year-3 residents could serve as discussants). Generalizable key elements of a patient encounter, including history and physical examination, are highlighted in Figure 2. The discussant receives only the information under Case Presentation Elements; the items under Case Reveal Elements are used by the coordinator to judge the quality of the case. The feedback form was modified to include the assessment of the resident discussant from the perspective of level-5 achievements. The highest-rated resident discussant represented the program at a statewide CPC competition. Faculty continued to serve as discussants at national competitions. 
Figure 2.
Essential patient encounter details for junior (year-1 and year-2) resident presentations during the internal annual clinical pathologic conference, which is used to demonstrate residents’ Accreditation Council for Graduate Medical Education emergency medicine Milestones, aid in faculty development, and increase academic output.
Figure 2.
Essential patient encounter details for junior (year-1 and year-2) resident presentations during the internal annual clinical pathologic conference, which is used to demonstrate residents’ Accreditation Council for Graduate Medical Education emergency medicine Milestones, aid in faculty development, and increase academic output.
To further improve manuscript output, the CPC coordinator collaborated with the EM research team to facilitate transition of appropriate CPC cases into peer-reviewed manuscripts that included medical students, residents, and faculty as authors. Faculty development time previously allocated to the internal competition was redirected toward writing cases for submission to peer-reviewed journals. 
Outcomes
To date, all residents in the EM Milestones Project attained level-5 achievement for Milestones 2, 3, 4, and 6, documenting residents’ ability to identify obscure pathology and avoid premature closure in their medical decision-making. Although not overtly measured on the feedback form, the CPC competition also serves to provide additional data for Milestones 2, level 4; 3, level 3; 4, levels 2, 3 and 4; and 6, level 4. 
In phase 1, the resident presentations won awards for 5 “Best Resident Presenter” honors at the statewide competition. Core EM faculty won 4 Best Faculty Discussant awards at the state level. One resident placed as a national Society for Academic Emergency Medicine/ACEP finalist. Core EM faculty and 1 resident placed as national runners-up. At the national American College of Osteopathic Emergency Physicians competition, 2 residents won the competition and 1 was a runner-up. At the same competition, 1 faculty member won and 2 were runners-up. In phase 2, only 1 case was selected to compete in the statewide competition. Seven of the residents competed, and 1, competing as a faculty discussant, received the runner-up award. Six case reports were published in peer-reviewed journals as a result.5-10 
Discussion
Residency program reporting of Milestone progress is required of all residency programs with ACGME accreditation or dually accredited programs and linked to continued accreditation.2,3 Although the clinical setting allows for documentation of many Milestones, residency participation in an internal CPC competition may demonstrate the ability of the resident to deliberately consider a case, which can be the basis of higher-level Milestone achievement. The CPC also serves to hone public speaking skills. Residents can gain valuable experience by presenting outside their home institution; they often have too few external academic presentation opportunities. 
Some of the reported Milestone success of residents in phase 2 may have resulted from dissemination of phase-1 feedback. The coordinator specifically mentored residents according to what the judges were looking for. That being said, if content from the ACEP Teaching Fellowship is accepted as an educational standard for a high-quality presentation, a culture of expectations around presentation quality is thus created, rather than a limitation of the coordinator “teaching to the test.”4 
Aside from resident education, programs need to provide faculty with their own academic development. It has been noted that faculty development mentorship is provided only about half of the time11 and should ideally include educational and research skills.12 This CPC project serves to meet both of these development goals, resulting in tangible internal and external data. Educationally, our project seeks to improve faculty presentation skills based on methods such as the ACEP Teaching Fellowship, and, by encouraging external presentations, also assists faculty in meeting ACGME publication expectations.2,3 Although case reports do not involve the scientific rigor of research studies, they do provide valuable experience with scientific writing and the process by which manuscripts are prepared, submitted, and revised for peer-reviewed literature. This process should provide a stronger foundation for faculty members to initiate their own research protocols and still meet the ACGME faculty productivity requirements.3 
Because case quality may affect performance at competitions and acceptance in the peer-reviewed literature, creating a culture by which all interesting cases are captured becomes important. Since the beginning of phase 2, a portion of intern orientation now includes an introduction of new residents to the CPC program. All residents are made aware that cases sent to the CPC coordinator may be used for either CPC competitions or case reports. Creating this proactive culture may improve success in both areas of productivity. While some project outcomes are specific to EM, the focus on gathering, discussing, and publishing high-quality cases can be generalized to other specialties. The emphasis of a CPC is on the cognitive process of moving from the case presentation through the relevant possible diagnoses to reach the ultimate answer, including a discussion of confirmation of the diagnosis through a criterion standard test. The specifics of the best cases to stimulate discussion and the definition of the criterion standard for diagnosis are most appropriately defined by the specific specialty conducting the CPC. With the single accreditation system for graduate medical education, this CPC competition may represent a means for residency programs to increase the professional development of both their residents and faculty, which also increases the measureable academic output of the residency program. 
Limitations
Factors that limit our project's generalizability include the availability of CPC competitions that a residency program can participate in. As a dually accredited EM program with an active statewide ACEP chapter, there are 3 statewide competitions in Pennsylvania that accept case submissions. In addition, competition success depends not only on the work ethic of the submitting resident but also on the strength of the cases and presenting skills of competing presenters. These are variables that cannot be standardized. Both the number of cases and judging standards can vary at different competitions. Also, successful publication of case reports in peer-reviewed journals is not an easily reproducible standard; there is wide variability in publication standards and acceptance rates across journals. 
Conclusion
The findings from this educational process-change Milestones Project describe the potential academic benefits of an internal CPC competition supported by a dedicated faculty coordinator to help residents achieve important ACGME Milestones, as well to aid in faculty development. In phase 1, the coordinator provided educational skill development for both resident and faculty academic presentations, which was recognized by external competition awards. In phase 2, feedback forms evolved to provide a means to successfully document ACGME Milestone level 5 competence for senior residents. An added benefit that resulted from the reduction of faculty time commitment to the internal competition served to improve faculty productivity through increased publication of case reports. 
Acknowledgments
We acknowledge Kristine A. Petre, MLS, CM, AHIP, and Micaela B. Wilson, BA, for their help with developing this manuscript. 
References
Bohm M. Preparing and presenting an emergency medicine clinical pathologic case conference (CPC). Council of Emergency Medicine Residency Directors website. http://www.cordem.org/i4a/pages/index.cfm?pageID=3295. Accessed on February 3, 2017.
Accreditation Council for Graduate Medical Education, American Board of Emergency Medicine. The Emergency Medicine Milestone Project. Chicago, IL: Accreditation Council for Graduate Medical Education; 2012.
ACGME Program Requirements for Graduate Medical Education in Emergency Medicine. Chicago, IL: Accreditation Council for Graduate Medical Education; 2016.
ACEP - teaching fellowship. American College of Emergency Physicians website. https://www.acep.org/tf/. Accessed February 3, 2017.
Bishop TM, Elsayed KS, Kane KE. Subdural hematoma as a consequence of epidural anesthesia [published online November 30, 2015]. Case Rep Emerg Med. 2015:597942. doi: 10.1155/2105/597942
Doan TT, Masom CP, Mazzaccaro RJ, Kane KE. Acute cerebellar ataxia: an unusual pediatric case. J Emerg Med. 2016;50(5):769-772. doi: 10.1016/j.jemermed.2016.01.025 [CrossRef] [PubMed]
Ahmadzadeh KL, Bhardwaj V, Johnson SA, Kane KE. Pediatric stroke presenting as a seizure [published online December 22, 2014]. Case Rep Emerg Med. 838537. doi: 10.1155/2014/838537
Myers PJ, Kane KE, Porter BG, Mazzaccaro RJ. Syndenham chorea: rare consequence of rheumatic fever. West J Emerg Med. 2014;15(7):840. doi: 10.5811/westjem.2014.8.22981 [CrossRef] [PubMed]
Rios RE, Villaneuva KM, Stirparo JJ, Kane KE. Recurrent (stump) appendicitis: a case series. Am J Emerg Med. 2015;33(3):480, e1-e2. doi: 10.1016/j.ajem.2014.08.050
Kane KE, Koons AL. The aortomesenteric angle as an aid in diagnosing superior mesenteric artery syndrome [published online March 16, 2017]. Clin Pract Case Emerg Med. doi: 10.5811/cpcem.2016.12.30676
Welch J, Sawtelle S, Cheng D, et al Faculty mentoring practices in academic emergency medicine. Acad Emerg Med. 2017;24(3):362-370. doi: 10.1111/acem.13136 [CrossRef] [PubMed]
McLaughlin SA. Faculty development. Acad Emerg Med. 2005;12(4):302e1-302e5. doi: 10.1197/j.aem.2005.01.003 [CrossRef] [PubMed]
Figure 1.
Timeline for junior (year-1 and year-2) residents to choose and prepare cases for discussion during the internal annual clinical pathologic conference (CPC), which is used to demonstrate residents’ Accreditation Council for Graduate Medical Education emergency medicine (EM) Milestones, aid in faculty development, and increase academic output. Abbreviation: H&P, history and physical examination.
Figure 1.
Timeline for junior (year-1 and year-2) residents to choose and prepare cases for discussion during the internal annual clinical pathologic conference (CPC), which is used to demonstrate residents’ Accreditation Council for Graduate Medical Education emergency medicine (EM) Milestones, aid in faculty development, and increase academic output. Abbreviation: H&P, history and physical examination.
Figure 2.
Essential patient encounter details for junior (year-1 and year-2) resident presentations during the internal annual clinical pathologic conference, which is used to demonstrate residents’ Accreditation Council for Graduate Medical Education emergency medicine Milestones, aid in faculty development, and increase academic output.
Figure 2.
Essential patient encounter details for junior (year-1 and year-2) resident presentations during the internal annual clinical pathologic conference, which is used to demonstrate residents’ Accreditation Council for Graduate Medical Education emergency medicine Milestones, aid in faculty development, and increase academic output.