24.1 Research methodology

Assembling the research team

Most research projects are undertaken as collaborative efforts with the co-investigators each contributing in their area of expertise. Co-investigators should meet the criteria for co-authorship of the publication reporting the study’s findings [3].

Usually, the person who has developed the research question takes the role of principal investigator (team leader) for the project. Among the first tasks is to assemble the research team. Ideally, the principal investigator determines the areas of expertise required for successful completion of the project (e.g. biostatistics) and invites appropriately skilled personnel to join the team [1]. It is advisable to keep the numbers within the team to a minimum. In most cases, three or four people are adequate to provide a range of expertise without the team becoming cumbersome. It is recommended that nursing staff be invited to join the team, if this is appropriate. This may foster research interest among these staff, improve departmental morale and may greatly assist data collection and patient enrolment.

All co-investigators are expected to contribute time and effort to the project, although the extent of this contribution will vary. The temptation to include very senior staff or department heads simply to bolster the profile of the project should be avoided if possible. It is recommended that personality and track record for ‘pulling one’s weight’ be considered when assembling the team. There is little more frustrating than having poor contributors impede the progress of a study. Assigning specific responsibilities, in writing, to each member of the team is a useful tactic in preventing this potential problem. However, care should be taken to ensure that the timelines for assignment completion are reasonable.

The importance of good communication within the research team cannot be overemphasized. This is usually the responsibility of the principal investigator and may involve regular meetings or reports. At the risk of flooding each co-investigator with excessive or trivial communications (e.g. e-mail), selected important communications should be forwarded as they appear, for instance, notification of ethics committee approval and updates on enrolment.

Development of the study protocol

The protocol is the blue print or recipe of a research study. It is a document drawn up prior to commencement of data collection that is a complete description of the study to be undertaken [4]. Every member of the study team should be in possession of an up-to-date copy. Furthermore, an outside researcher should be able to pick up the protocol and successfully undertake the study without additional instruction.

Purpose of the study protocol

Research protocols are required:

Protocol structure

The protocol should be structured largely in the style of a journal article’s Introduction and Methods sections [4]. Hence, the general structure is as follows:

Introduction

Methods

This general plan should be followed in the preparation of any study protocol. However, the final protocol will vary from study to study.

Study design

Study design, in its broadest sense, is the method used to obtain data to weigh up the evidence for and against the study hypothesis. Many factors influence the decision to use a particular study design and each design has advantages and disadvantages. For a more extensive discussion on study design the reader is referred elsewhere [1,5].

Observational studies

In general, research studies examine the relationship between an exposure or risk factor (e.g. smoking, obesity, vaccination) and an outcome of interest (e.g. lung cancer, cardiac disease, protection from infection).

In observational (non-experimental) studies, the principal challenge is to find a naturally occurring experiment, i.e. a comparison of two or more populations that enables the investigator to address a hypothesis about the outcome of interest.

Cross-sectional studies

Cross-sectional studies examine the present association between two variables. For example, within a population you could take a single random sample of all persons, measure some variable of interest (e.g. lung function) and then correlate that variable with the presence or absence of lung cancer. Data are often collected in surveys and the information on exposure and outcome of interest is collected from each subject at one point in time. The main outcome measure obtained from a cross-sectional study is prevalence.

Ecological studies

Ecological studies relate the rate of an outcome of interest to an average level of exposure that is presumed to apply to all persons in the population or group under investigation. So, for example, we could determine the association between the average amount smoked per capita in different countries and the incidence of lung cancer in each country.

Cohort studies

In a cohort study, a group of individuals, in whom the personal exposures to a risk factor have been documented, are followed over time. The rate of disease that subsequently occurs is examined in relation to the individuals’ exposure levels. For example, within a population you could take a sample (cohort) of healthy individuals, document their personal past and ongoing smoking history, and relate that to the subsequent occurrence of lung cancer in that same sample. Although not as powerful a study design as clinical trials (see below), cohort studies are able to provide valuable data relating to the causation of disease.

Case-control studies

Case-control studies involve a comparison between a representative sample of people with an outcome of interest (cases) and another sample of people without the outcome (controls). If an antecedent feature (exposure) is found to be more common in the cases than the controls, this suggests an association between that exposure and the development of the outcome. The frequencies of past exposures to risk factors of interest are compared in each group. Case-control studies provide only medium level evidence of an association between exposure and outcome of interest.

Case reports and case series

This study design is often employed in emergency medicine research. The clinical details (history, management, outcome) of interesting or similar patients are described. This study design provides weak evidence for an association between exposure and outcome of interest and is best employed for hypothesis generation. For example, a series of patients who all developed skin necrosis after being bitten by a certain spider would reasonably lead to the hypothesis that the venom of the spider of interest contained a particular tissue necrosis factor. However, this hypothesis would need to be proven by the isolation of the factor and experimental demonstration of its effects.

Data for case reports/series are often extracted from medical record reviews or existing databases. This is one reason for the weakness of this study design insofar as the data were most likely collected for purposes other than the research study. Accordingly, such data are often of low quality and may suffer from inaccuracies, incompleteness and measurement bias.

Experimental studies

In an experimental study, the researcher is more than a mere observer and actively manipulates the exposure of study subjects to an exposure of interest (risk) and measures the effects (outcomes) of this manipulation.

The preferred form of experimental study is currently the randomized, controlled trial, in which the intervention is randomly assigned at the level of the individual study subject. Although this is the most scientifically rigorous design, other study designs must often be used for a number of reasons including:

For ethical reasons, we cannot easily use experimental studies to study factors that are thought to increase the risk of disease in humans. For example, you could not do a study where you ask half of the group to smoke for 10 years and half of the group to remain non-smokers.

Main types of clinical trials

Key features of clinical trials

Randomization

This is a process by which patients are allocated to one of two or more study groups, purely by chance. Randomization prevents any manipulation by the investigators or treating doctors in the creation of the treatment groups. This prevents a situation whereby a doctor can, for example, allocate the sicker (or not so sick) patients to a new treatment. Randomization also helps to produce study groups comparable to one another with respect to known, as well as unknown, confounding variables (e.g. risk factors). The most convenient methods of randomizing patients are random number tables in statistical textbooks or computerized random-number-generating programs.

A fundamental aspect of randomization is that it must only take place after the commitment to participate has been made (enrolment has taken place). Another important principle is that randomized patients are irrevocably committed to follow up and must not be excluded from, or lost to, follow up, regardless of their subsequent compliance or progress (‘intention to treat analysis’).

Blinding

Blinding is the most effective method of minimizing systematic error (bias) in clinical trials. In single-blinded studies, patients participating in the trial are unaware which treatment they are receiving but the investigators do know. In double-blind studies, neither the subjects nor the investigators know which patient is receiving which treatment. This type of study is usually only feasible with drug studies where it is possible to provide identically appearing medication. This is often achieved using the double dummy approach in which patients receive two medications, one active and the other placebo. The alternative treatment involves a swap-over of the active and placebo medications. Even in apparently blinded studies, there may be various indicators that allow the patient or investigator to determine which treatment they are receiving. In this circumstance, additional methods of bias control may be needed.

Concepts of methodology

Validity and repeatability of the study methods

It is essential that the study uses valid and repeatable methods, that is, measurements that measure what they purport to measure. Ideally, the validity of each of the measurements used in any study should be tested, during the design stage of the study, against another method of measuring the same thing that is known to be valid.

Two types of validity are described:

Response rate

Non-response is a problem for many types of observational study. Often people who participate in a study (responders) have different characteristics from those who do not (non-responders). This can introduce substantial selection bias into the prevalence estimates of a cross-sectional study. In order to minimize this bias, as large a sample as possible is required. To this end, investigators undertaking cross-sectional surveys aim for at least 70% of invited participants actually to respond. Unfortunately, a target response rate of 70% is often not met and low response rates are likely to impact significantly upon bias and validity of the study.

Study variables

A variable is a property or parameter that may vary from patient to patient. The framework for the study hypothesis is the independent variable. This variable is often the factor that is thought to affect the measurable endpoints, or dependent variables, in the study. For example, cigarette smoking causes lung cancer. In this example, cigarette smoking is the independent variable and lung cancer is the dependent variable, as its incidence and nature depends upon cigarette smoking.

Study endpoints

Study endpoints are variables that are impacted upon by the factors under investigation. It is the extent to which the endpoints are affected, as measured statistically, that will allow us to weigh up the evidence for and against the hypothesis. For example, a researcher wishes to examine the effects of a new anti-hypertensive drug. It is known that this drug has minor side effects of impotence and nightmares. A study of this new drug would have a primary endpoint of blood pressure drop and secondary endpoints of the incidence of the known side effects.

Essentially, all forms of investigation involve counting or measuring to quantify the study endpoints. In doing so, there is always the opportunity for error, either in the measurement itself or in the observer who makes the measurement. Such errors (measurement bias) can invalidate the study findings and render the conclusions worthless.

Sampling study subjects

There are several important principles in sampling study subjects:

Sampling frame

This is a list of all members (for instance persons, households, businesses) of the target population that can be used as a basis for selecting a sample. For example, a sampling frame might be the electoral roll, the membership list of a club or a register of schools. It is important to ensure that the sampling frame is complete, that all known deficiencies are identified and that flaws have been considered (omissions, duplications, incorrect entries).

Sampling methodology

Probability sampling

When every member of the population has some known probability of inclusion in the sample, we have probability sampling. There are several varieties:

Simple random sampling: in this type of sampling, every element has an equal chance of being selected and every possible sample has an equal chance of being selected. This technique is simple and easy to apply when small numbers are involved, but requires a complete list of members of the target population.

Systematic sampling: this employs a fixed interval to select members from a sampling frame. For example, every twentieth member can be chosen from the sampling frame. It is often used as an alternative to simple random sampling as it is easier to apply and less likely to make mistakes. Furthermore, the cost is less, its process can be easily checked and it can increase the accuracy and decrease the standard errors of the estimate.

Stratified sampling

A stratified sample is obtained by separating the population into non-overlapping groups or strata (e.g. males and females) and then selecting a single random (or systematic) sample from each stratum. This may be done to:

However, the strata should be designed so that they collectively include all members of the target population, each member must appear in only one stratum and the definitions or boundaries of the strata should be precise and unambiguous.

Non-probability sampling

Convenience sampling is an example of non-probability sampling. This technique is used when patients are sampled during periods convenient for the investigators. For example, patients presenting to an emergency department after midnight are much less likely to be sampled if research staff are not present. This technique is less preferred than probability sampling, as there is less confidence that a non-probability sample will be representative of the population of interest or can be generalized to it. However, it does have its uses, such as in in-depth interviews for groups difficult to find and for pilot studies.

Data-collection instruments

Surveys

Surveys are one of the most commonly used means of obtaining research data. While seemingly simple in concept, the execution of a well-designed, questionnaire-based survey can be difficult.

Designing a survey

From a practical point of view, the following points are suggested:

Before a survey

During the survey

After the survey

If possible, incorporate commonly asked questions into your questionnaire. One good source of such questions is standard surveys (such as Australian Bureau of Statistics). There are many other sources of pre-validated questions (for instance measures on quality of life, functional ability and disease-specific symptoms). The scientific literature, accessible through MEDLINE and other databases, is a good start. This is particularly important if you want to compare the sample with other surveys or, in general, if you want to be able to compare the sample’s responses to previously completed work.

Also, previously used questionnaires for similar topics are very helpful and often can be used directly. The advantage to doing this is that these questionnaires’ reliability and validity are established.

The wording of a question can affect its interpretation. Attitude questions with slightly different wordings can elicit differing responses, so several questions on the same topic may be helpful to be certain that the ‘true attitude’ of the respondent is obtained. This technique can enhance internal validity and consistency.

Pre-testing of a questionnaire is most important. Consider the following points:

It is always worth checking with your colleagues to determine whether the questionnaire will answer the study question. Also, test the questionnaire on a cross-section of potential respondents of differing reading levels and background. There can be a few surprises and several revisions may be required before the final questionnaire is determined.

Data-collection proformas

These documents, also called case report forms, are generally used to record individual case data that are later transferred to electronic databases. These data may be obtained from the patient directly (e.g. vital sign measurements) or extracted from the medical records or similar source.

While simple in concept, careful design of a data-collection proforma should be undertaken. First, a list of the data required should be drafted and translated into data fields on the proforma. These fields should be clearly laid out and well separated. Prior to data collection, the proforma should be trialled on a small selection of subjects. In such an exercise, it is commonly found that the data fields are not adequate for the collection of the required data. Hence, revision of the proforma is often required.

Consideration should be given to the ease of data entry and extraction from the proforma. Data entry should progress logically from the top to the bottom of the document without interruption. This is particularly important for data extraction from medical records. Data extracted from the front of the record should be entered at the top of the proforma and so on. Consideration should also be given to later translation of the data to an electronic database. This should follow the same principles as described above. If possible, design a proforma that will allow data to be scanned directly into an electronic database.

Bias and confounding

Study design errors

In any study design, errors may occur. This is particularly so for observational studies. When interpreting findings from an observational study, it is essential to consider how much of the association between the exposure (risk factor) and the outcome may have resulted from errors in the design, conduct or analysis of the study [5]. The following questions should be addressed when considering the association between an exposure and outcome:

Systematic error (bias)

Bias resulting from the way a study is designed or carried out can result in an incorrect conclusion about the relationship between an exposure (risk factor) and an outcome (such as a disease) of interest [5]. Small degrees of systematic error may result in high degrees of inaccuracy. Many types of bias can be identified:

Confounding

This is not the same as bias. A confounding factor can be described as one that is associated with the exposure under study and independently affects the risk of developing the outcome [5]. Thus, it may offer an alternative explanation for an association that is found and, as such, must be taken into account when collecting and analysing the study results.

Confounding may be a very important problem in all study designs. Confounding factors themselves affect the risk of disease and, if they are unequally distributed between the groups of people being compared, a wrong conclusion about an association between a risk factor and a disease may be made. A lot of the effort put into designing non-experimental studies is in addressing potential bias and confounding. For example, in an often-cited case-control study on the relationship between coffee drinking and pancreatic cancer, the association between exposure and disease was found to be confounded by smoking. Smoking is a risk factor for pancreatic cancer; it is also known that coffee drinkers are more likely to smoke than non-coffee drinkers. These two points create a situation in which the proportion of smokers will be higher in those who drink coffee than in those who do not. The uneven distribution of smokers then creates the impression that coffee drinking is associated with an increased rate of pancreatic cancer when it is smoking (related to those who drink coffee and to pancreatic cancer) that underlies the apparent association.

Common confounders

Common confounders that need to be considered in almost every study include age, gender, ethnicity and socioeconomic status. Age is associated with increased rates of many diseases. If the age distribution in the exposure groups differs (such as where the exposed group is older than the non-exposed group) then the exposed group will appear to be at increased risk for the disease. However, this relationship would be confounded by age. Age would be the factor that underlies the apparent, observed, association between the exposure and disease. Although age is a common confounder, it is the biological and perhaps social changes that occur with age that may be the true causes that increase the rate of disease.

There are several ways to control for the effect of confounding. To control for confounding during the design of the study, there are several possible alternatives:

In the analysis phase of a study, one can use:

Principles of clinical research statistics

Sample size

The sample must be sufficiently large to give adequate precision in the prevalence estimates obtained by the study for the purposes required. The most common mistake made by inexperienced researchers is to underestimate the sample size required. As a result, the sample size may be too small and not representative of the population that the sample is meant to represent. This usually leads to outcome measures that have very wide 95% confidence intervals and, hence, statistically significant differences between study groups may not be found.

To ensure that a study has adequate sample sizes to show statistically significant differences, if they are there, sample sizes should be calculated prior to the study commencement. In reality, sample size is often determined by logistic and financial considerations, that is to say a trade-off between sample size and costs.

Study power

The power of a study is the chance of correctly identifying, as statistically significant, an effect that truly exists. If we increase the sample size, we increase the power. As a general rule, the closer the power of a study is to 1.0, the better. This means that the type II error will be small, that is there will be only a small chance of not finding a statistical difference when there really is one. Usually, a power of 0.8 or more is sufficient.

Statistical versus clinical significance

To determine statistical significance, we can obtain a P value, relative risk or some other statistical parameter that is indicative of a difference between study groups. However, a statistical difference (e.g. P<0.05) between groups may be found if the study is highly powered (many subjects), even though the absolute difference between the groups is very small and not a clinically significant (meaningful) difference.

This difference is important for two reasons. First, it forms the basis of sample size calculations. These calculations include consideration of what is thought to be a clinically significant difference between study groups. The resulting sample sizes adequately power the study to demonstrate a statistically and clinically significant difference between the study groups, if one exists. Second, when reviewing a research report, the absolute differences between the study groups should be compared. Whether or not these differences are statistically significant is of little importance if the difference is not clinically relevant. For example, a study might find an absolute difference in blood pressure between two groups of 3 mmHg. This difference may be statistically significant, but too small to be clinically relevant.

Databases and principles of data management

The fundamental objective of any research project is to collect information (data) to analyse statistically and, eventually, produce a result. Data can come in many forms (laboratory results, personal details) and are the raw material from which information is generated. Therefore, how data are managed is an essential part of any research project [4].

Defining data to be collected

Many a study has foundered because the wrong data were collected or important data were not collected. Generally, data fall into the following groups:

Collect only the research data that are essential to answer the study question. Collection of data that will not be of use is time-consuming, expensive and may detract from the quality of the remaining data. However, there will usually be a minimum of data that must be collected. If these data are not collected, then the remaining data may not be analysed adequately. This relates particularly to data on confounding factors.

Database design

A database is a specific collection of data that is organized in a structured fashion. In other words, database software provides us with a way of organizing the data we collect from a research project in a systematic way.

Good database design will:

Data entry

This refers to the entry of data into the electronic database, e.g. Access, Excel. Even if the study design and the data collection have been well done, the final data set may contain inaccurate data if the data-entry process is inadequate. This relates particularly to manually entered data where mistakes are bound to happen.

Data entry can be achieved in many ways:

Data validation

Effectively, this is a quality assurance process that confirms the accuracy of the data and can be done in the following ways:

Research ethics

Participation in a clinical trial may involve a sacrifice by the participant of some of the privileges of normal medical care for the benefit of other individuals with the same illness. The privileges forgone might include:

Participation may also require the discomfort and inconvenience associated with additional investigations and the potential incursion on privacy. Without the willingness of some individuals to make these sacrifices, progress in clinical medicine would be greatly impaired. Most individuals who now expect to receive safe and effective medical care are benefiting by the sacrifices previously made by other individuals.

Some have argued, in contrast, that enrolment into clinical trials ensures the absolute best care currently available, with greater involvement and scrutiny by attending healthcare teams.

If one accepts that clinical trials are morally appropriate, then the ethical challenge is to ensure a proper balance between the degree of individual sacrifice and the extent of the community benefit. However, it is a widely accepted community standard that no individual should be asked to undergo any significant degree of risk regardless of the community benefit involved, that is, the balance of risks and benefits must be firmly biased towards an individual participant.

Because of the trade-offs required and because of the spectrum of views about the degree of personal sacrifice that might be justified by a given community benefit, it is accepted that all clinical trials should be reviewed by an ethics committee that should have as a minimum:

Scientific value

It is unethical to request individuals to undergo the risks and inconvenience of a study that is unlikely to provide a scientifically worthwhile result. It is also unethical to request sacrifices from volunteers that are out of keeping with the value of the research being undertaken. In keeping with this principle, studies that suffer from substantial design errors or are susceptible to serious bias should not be approved until these deficiencies are remedied.

It is unethical to allow scientifically invalid studies to proceed. Sample-size calculations should be scrutinized because of the ethical undesirability of including too few subjects to provide an answer or many more than is needed to provide a convincing answer. Another safeguard to ensure that the research will be valuable is that the investigator should be qualified, experienced and competent, with a good knowledge of the area of study and have adequate resources to ensure its completion.

Benefits forgone

It is unethical to require any patient to forgo proven effective treatment during the course of a trial. It follows that clinical trials should only be undertaken when each of the treatments being compared is equally likely to have the more favourable outcome.

Very commonly, however, there is an expectation before a trial is commenced that one or other treatment is the more beneficial. This may be based on results of uncontrolled studies or even on biochemical or physiological expectations. The large number of times such expectations have been proven wrong can still provide strong justification for a trial.

If such an expectation of benefits is held strongly by an individual, it is probably not ethical for that individual to participate in a study. Furthermore, it is the responsibility of an ethics committee to assess the strength of the presumptive evidence facing one or other treatment and consider whether any substantial imbalance in likely outcome exists. This must be considered in relation to the importance of the question being addressed.

Informed consent

Participants in clinical trials have a fundamental right to be fully informed about the nature of a clinical trial and to be free to choose whether or not to take part. Ethical principles also dictate that prospective participants be:

It is usual practice to provide prospective participants with a Participant Information and Consent Form that provides a simple, easy to understand account of the purposes, risks and benefits associated with participation in the study. Ethics committees are required to review these statements and confirm that they provide a reasonable account.

In practice, the procedures involved in obtaining informed consent are often problematic. Considering the dependence of sick patients on the health system, their anxiety and their desire to cooperate with their physicians, it is doubtful whether informed consent is ever freely given. When ethics committees identify situations where this scenario is likely to be a particular problem, the involvement of an independent uninvolved person to explain the study may be useful.

24.2 Writing for publication

Readability

To get your message across, it must be accessible to the reader. This is best achieved by avoiding long sentences, using simple words and avoiding jargon. Abbreviations should be kept to a minimum and always defined in the paper at their first use.

Manuscript preparation

Original research manuscripts

Original research manuscripts aim to answer a relevant research question. Defining that question, indicating why it is important, what methods were used to answer it, key findings and their interpretation is the purpose of this type of paper. An original research manuscript is usually divided into five sections: Abstract, Introduction (or Background), Methods, Results and Discussion. In addition, some journals prefer a separate concise Conclusion, although many prefer this as the last paragraph of the Discussion. Uncommonly, journals have additional section headings, such as Theoretical Concept and Limitations. It is very important to check the journal’s preferred format for each section and ensure the manuscript complies. Most manuscripts also require a key word list of up to five words or phrases to assist with indexing.

Abstract

This is a very important part of the paper as it is the part that will appear in on-line indexing services. The usual word limit is 250 words under the headings ‘Objectives’, ‘Methods’, ‘Results’ and ‘Conclusion’. There is considerable variation between journals about how the abstract section is set out. Some prefer a single paragraph without subheadings but many of the major journals require structured abstracts with particular subheadings. These are detailed under Instructions for Authors.

The abstract should contain all key data. In particular, the specific aims, methods, outcomes of interest, main results (with numbers) and conclusions should be clear enough to be understood without the support of the text. It is important that no data or conclusions appear in the abstract that have not been presented in the main body of the paper.

Introduction

Shorter introductions are often more effective. The aim is to convince the reader why the area of study is important, what this study adds to the body of knowledge and the specific aims of the study. A lengthy review of the literature should be avoided unless it is imperative to put the study in context. A concise review of the literature is more appropriately reported in the Discussion. The last paragraph should explicitly state the aims of the study.

Methods

The Methods sections should address a number of headings. Some journals like this done explicitly, while others are happy for it to be rolled into logical paragraphs.

Results

It is important for the results to be presented logically and for the relationships with the objectives and methods to be obvious. A useful structure is to start by describing the study population. This should include how it was derived (a summary figure such as a Consolidated Standards of Reporting Trials (CONSORT) diagram may be very effective for this) and its features such as gender, age and so on.

This should be followed by descriptions of the results with respect to stated outcomes of interest: primary outcomes first then secondary outcomes. These should align with the stated objectives. Any subgroup or other analysis should follow this. All results should give the appropriate statistics with confidence intervals (if appropriate) and the type of test used. A significant proportion of journals are moving away from P values as a way of expressing statistical significance, instead preferring effect size with confidence intervals (or similar). Avoid any comments on what the results might mean or why they might have occurred. Interpretation of the results belongs in the Discussion section.

Tables and figures can be very effective ways of communicating results. They should not repeat what can be described adequately in the text. All tables and figures should be self-explanatory, with clear descriptive headings. Tables should be constructed so that the main comparisons of interest are horizontal and left-to-right, with number of subjects clearly shown for each column. Graphs or figures should be used to convey patterns and details that cannot be succinctly conveyed in tables or text. Figures that show the distribution of data (scatterplots, box plots, etc.) are more effective than those simply summarizing data (bar graphs, pie charts, etc.). Axes must be clearly labelled. Tables and figures should be kept to the minimum number needed to convey the information, and should be numbered in the convention of the journal.

Discussion

The Discussion should be concise and to the point and can be challenging. This structure may assist:

Case reports

Fewer journals are accepting case reports. Those accepted for publication tend to have an exceptional element or important clinical message, either in terms of an unusual diagnosis, an innovative use of tests or treatments or an unusual adverse event. It is not enough for a case to simply be ‘interesting’.

The usual structure for a case report is an abstract of about 100–150 words summarizing the case and the clinical messages, the case report itself and a discussion. The case should be described in sufficient detail for the reader to be confident of the evidence. The Discussion is the key element of a case report. It usually includes a review of the literature and uses the case to draw out important clinical messages. It needs to be logical in idea development and well referenced.

Systematic reviews and meta-analyses

A systematic review is a summary of primary studies. It aims to answer a clinical or research question by using strategies that limit bias, critically appraise and synthesize all relevant studies on a selected topic. A meta-analysis is a mathematical synthesis of the results of primary studies addressing the same question in a similar way.

A detailed description of the methods for systematic reviews and meta-analyses is beyond the scope of this chapter. That said, they share several aspects with original research including definition of a research question, development of a research protocol, literature search/review, data analysis and interpretation.

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses; www.prisma-statement.org) checklist is an evidence-based minimum set of items aimed at assisting authors improve the quality of systematic reviews and meta-analyses. Many journals require the submission of a PRISMA checklist when review articles are submitted.

Letter to the editor

These are short communications, usually 500–600 words in length. Most often they comment on a recently published paper in the journal concerned, but they may also be used to report a case or case series, an observation or an opinion.

Manuscript submission

Most journals require online submission of manuscripts. This is good for authors as it significantly reduces turn-around time. The sites vary in the way they want material entered, so it is important to check this.

A manuscript must only be under consideration by one journal at a time. Authors will be required to attest to this and to the fact that appropriate ethics approvals were obtained.

The cover letter

Whether manuscripts are submitted electronically or in hard copy, a cover letter is usually required. This is often quite short and includes a request for consideration for publication in the journal concerned, a statement that the paper has not been published and is not under consideration by another journal, a statement regarding ethics approvals and a note of the presence or absence of author conflicts of interest.

The cover letter is also an opportunity to alert the editor to other issues that may be important. For example, if the manuscript overlaps with previously published work or another manuscript such that there might be a possibility of duplicate publication, it allows the editors to assess any overlap for themselves. Alternatively, it also provides the opportunity to identify potential reviewers that the authors believe should be avoided, usually because of actual or perceived conflicts of interest.

Feedback from journals

It is quite rare for manuscripts to be accepted ‘as is’. Usually, some revision is required and, in some cases, manuscripts are rejected. Neither of these necessarily implies that the study or material is not worth publication. It may simply be that the editors consider that their journal is not appropriate for the subject matter of the paper. Seriously consider the comments given, which are often detailed, and decide whether the issues can be addressed. If so, it is important to undertake a revision and re-submit as soon as practical. If the journal requested revisions and the concerns can be addressed, re-submit to that journal, otherwise submit to another journal after notifying the initial journal that the paper will not be re-submitted to them. Reformatting as a short report or letter to the editor are sometimes alternative ways to get your findings published.

Post-acceptance issues

There are usually several actions required post-acceptance. These include completion of assignment of copyright forms and checking the proofs of the paper. The publisher will usually manage these processes.

24.3 Principles of medical education

Feedback to learners

Feedback is a crucial requirement for learning and the importance of positive feedback for learning has been well established [34]. Feedback should provide the learner with information that offers ‘insight into what he or she did as well as the consequences of his or her actions’ [35]. It should allow the learner to know what went well and what could be improved or changed next time. Feedback is part of the formative assessment process that occurs throughout the learning period, rather than as a summative assessment that is to determine a grade or make a final judgment.

Effective feedback has a number of characteristics [36,37]. It should be given in a suitable environment to allow privacy and maintain confidentiality for the learner. There should be adequate time to allow the learner and the facilitator to explore the observed behaviour or skill. There should be clear goals established at the beginning of the learning so that feedback can be related to these goals. The feedback should come from direct observation of the learner’s performance where possible.

Providing learners with feedback is a specific skill in itself and requires practice to develop. A structured approach to giving feedback will assist the teacher/facilitator to provide effective and useful feedback. There are many models of feedback in the literature; however, one such model from Pendleton’s [38] work is suggested here to assist the ED physician:

Feedback, when delivered effectively, is a strong motivator to the adult learner and encourages ongoing performance review and reflection by the learner.

Conclusion

Juggling the demands of a being a busy emergency physician requires balancing clinical, administrative and teaching duties. Time is often limited and yet the rewards of being involved in teaching are obvious. Apart from personal satisfaction gained from interacting with junior colleagues, the ability to keep up to date and the opportunity to reflect on one’s own performance are enhanced. Reviewing performance as a teacher and practising education techniques to improve the effectiveness of the facilitation motivate the teacher to continue to teach and improve the satisfaction from teaching. Structuring learning experiences, considering learner needs and providing effective feedback are essential for learners in the ED environment.

Likely developments over the next 5–10 years

24.4 Undergraduate teaching in emergency medicine

Essentials

1 Medical student teaching needs to be considered one of the core businesses of an emergency department.

2 The specialty of emergency medicine has a unique body of knowledge that can contribute much to the entire undergraduate curriculum and it is essential that emergency physicians ‘own’ this knowledge.

3 To be effective educators, academic emergency physicians need to adopt a strategic and comprehensive approach to curriculum development, delivery and assessment throughout all years of the medical course.

4 It is essential that goals and objectives of student education in emergency medicine be clearly defined and articulated to all staff so that a consistent and integrated curriculum is delivered.

5 The specialty is playing a critically important role in medical student education as numbers of students rapidly increase and models of healthcare continue to change.

6 Emergency physicians are ideally placed to be able to introduce new and emerging topics in healthcare and to embrace innovative teaching methods, such as simulation and mobile learning.

Introduction

Emergency medicine now plays a central role in medical curricula in undergraduate and postgraduate medical schools in Australia and New Zealand. This is not unexpected, as the principles and practice of the specialty have much in common with the desired features of contemporary medical education: it is problem focused, interdisciplinary and integrates many aspects of community-based and hospital-based clinical practice. Clinical practice easily integrates and builds upon the biomedical sciences traditionally taught early in the medical course. Much growth in academic emergency medicine has occurred in the last two decades, with the establishment of academic departments and dedicated university positions. However, the majority of medical student teaching is performed by emergency physicians in clinical practice in public and an increasing number of private emergency departments (EDs). This chapter will address the issues surrounding medical student teaching at the departmental and the broader faculty level.

Overview of undergraduate medical education in Australia

It is important for emergency physicians interested in teaching medical students to be aware of recent trends and developments in medical education in Australasia. The CanMEDS 2000 Project and the World Health Organization, among others, have listed the key outcomes expected of a doctor [1]. These outcomes have been adopted by many schools worldwide as a basis for reform and reorganization and are listed in Table 24.4.1. Of interest, these principles have been embraced at the early postgraduate level through the Australian Curriculum Framework for Junior Doctors [2] and at a specialty college level, such as the Australasian College for Emergency Medicine’s Curriculum Revision Project [3]. Some schools have adopted problem-based learning as a tool to achieve these educational outcomes, with others using case-based and outcomes-based learning to place content in a clinical context. In 2010, the US-based Carnegie Foundation (which published the landmark Flexner Report in 1910) published a comprehensive review of current physician education and the need for reform which should be essential reading for any prospective medical educator [4].

Table 24.4.1

Essential roles and key competencies of specialist physicians – the CanMEDS criteria [1]

Medical expert

Communicator

Collaborator

Manager

Health advocate

Scholar

Professional

Copyright © 1996 The Royal College of Physicians and Surgeons of Canada. http://www.royalcollege.ca/portal/page/portal/rc/canmeds. CanMEDS 2000 Project skills for the new millennium: Report of the societal needs working group. Reproduced with permission.

Curriculum reform has occurred in parallel with significant changes in the health system, with a growth in information technology, changing patient expectations and a massive increase in medical knowledge. Models of healthcare delivery are changing, with increased pressures on public hospitals, such as access block, the unsustainable increase in health spending in relation to all other public spending, declining numbers of inpatient beds and the increasing complexity of medical conditions. The shift to the home and community management of many conditions has altered the patient mix available for student teaching. University salaries have not kept pace with the growth in public and private medical salaries, which has contributed to a decline in numbers of academic faculty and core medical school functions often shifting to sometimes reluctant specialists within the public hospital system. Despite this, there has been an increasing number of medical students and medical schools, with 3770 medical students commencing study in Australia in 2011 [5]. It is in this changing environment that emergency medicine has established itself as a key part of modern medical curricula and the specialty is poised to play an even greater role in the training of future doctors. Both the need and the opportunity exist for such expansion.

The importance of medical student teaching

Many clinicians feel that the provision of clinical care is the core business of an emergency department (ED) and hence may not be initially willing to allocate resources for teaching students. Similarly, university medical schools may not be aware of the growth of emergency medicine as a specialty and hence may not be aware of what it can offer students or, indeed, may not even be aware that it is an independent specialty with its own body of knowledge. However, once established, a strong academic presence can contribute to departmental morale, quality of care, performance and the standing of the department within the hospital and community. Table 24.4.2 lists the benefits of emergency medicine teaching to students, EDs and medical schools. These points may be used to argue for an increased presence and accompanying resources within a curriculum [6]. Resources and a formal place in the curriculum often come only after years of hard work in establishing the bona fides of emergency medicine. This may require much time and effort from a dedicated individual.

Table 24.4.2

Benefits of medical student teaching in emergency departments

Benefits to students

Usually an enjoyable term with unparalleled pathology and clinical experience  Integrates theoretical knowledge with the workplace  Learns acute care resuscitation skills  The opportunity to see patients before anyone else in the system  Emergency medicine is the embodiment of an equitable and accessible healthcare system

Benefits to the emergency department and hospital

Students gain a positive view of the specialty and this may influence subsequent career choice  May improve subsequent intern performance  Improves the overall professionalism and reputation of the department  Teaching is a core business of a hospital and should be embraced  May assist with recruitment and retention of staff with an interest in teaching  Students can assist with procedures and may improve patient flow in some circumstances

Benefits to the medical school

Allows access to a large number of patients with a broad range of clinical conditions otherwise not available for teaching  Allows access to a large pool of medical and nursing staff otherwise not available for teaching  Emergency medicine can teach knowledge and skills not readily taught by other disciplines, such as resuscitation, health systems and time management

Curriculum development

Undergraduate emergency medicine in the past was ad hoc, unstructured and highly selective, in that clinical exposure was based around what the students themselves thought was interesting and useful in the department at the time. With the growth of the specialty as an academic discipline, departments have been able to take a more active role in education, control student entry to the department, ensure appropriate orientation and attempt to take advantage of the rich and broad clinical experience on offer. As faculties have become aware of the learning opportunities on offer in EDs, as well as the teaching abilities of staff, emergency physicians have been able to negotiate a greater role in university affairs and integrate emergency medicine into the broader undergraduate curriculum. With this comes a responsibility for emergency physicians to understand the function of universities and the requirements which come with running an academic term. Table 24.4.3 provides suggestions for developing a university teaching presence.

Table 24.4.3

Minimum requirements for developing student placements in emergency departments

Nominate one person to be the term coordinator and liaison with the university  Understand the rules and regulations which govern student placements in your hospital and at the affiliated university  Develop a clear orientation package for students and make it clear that students will not be allowed into the department until they have received orientation  Develop a clear curriculum statement providing a broad overview of goals and objectives for the term (see Table 24.4.4)  Define specific learning objectives for students, e.g. ‘At the end of this placement you will be able to describe the assessment of the patient presenting with chest pain’  Consider how students will be assessed and clearly describe this prior to the commencement of the term  Consider who will supervise the students, for this reason it is essential to engage with all levels of staff within the department and to provide them with support, training and guidance

It is essential that once a department has decided that medical student teaching should be a part of its function then a curriculum must be considered. The Australasian College for Emergency Medicine, the American College of Emergency Physicians and the International Federation of Emergency Medicine have produced documents with varying degrees of detail concerning this [7–9] and a growing number of papers are being published providing guidance to curriculum developers [10,11]. Most core curriculum statements contain elements which reflect the clinical practice of emergency medicine and an example of such a list is provided in Table 24.4.4. This provides a framework around which specific topics can then be taught. The teaching programme will need to be modified and adapted accordingly depending upon the expertise of and time available to specialists within the department, as well as the local epidemiology and patient demographics.

Table 24.4.4

Suggested core curriculum topics in emergency medicine

Assessment and management of the undifferentiated patient

Key practical skills: basic life support skills and basic procedural skills

Recognition and management of the seriously ill and injured patient

The assessment and management of common clinical problems in emergency medicine

Assessment and management of the unwell child

Acute pain management

Acute mental health

Toxinology and toxicology

Health systems management

Critical thinking and clinical decision making

Safety and quality in healthcare: medical error and handover

Professional issues: teamwork, communication, time management

Care of the elderly and end-of-life issues

An often overlooked but essential component to consider is that of the ‘hidden curriculum’. This is less well understood, but relates to what students learn by being exposed to the practice of medicine. It can cover aspects such as professionalism, ethics and physician behaviour. As the vanguard of a fair, accessible and equitable health system, emergency medicine can teach important attitudes to the next generation of doctors.

Methods of teaching emergency medicine

Once teaching content is decided upon, then it is worth spending time considering which format is the best way to deliver the material. Until recently, undergraduate emergency medicine has largely been taught in the workplace and no other teaching options have existed. However, with the growth of the specialty and the increased need for teachers, the specialty has been able to attract resources and play a greater role in all years of the medical course in some universities. Therefore, depending upon available time and resources, different formats of teaching should be considered for different situations. For example, resuscitation skills are best taught using team-based simulation and practice to reflect the reality of the workplace, once basic concepts have been covered by lectures or online modules.

In all formats, teachers should consider the basic principles of adult learning and teach accordingly. When delivering material, teachers should remember that adults learn best when the topic is meaningful, linked to experience and pitched at the correct level and the students are motivated, have clear goals, are actively involved, receive regular feedback and have time for reflection [12]. Utilizing a range of methods means that material can be delivered in a meaningful way and optimal learning conditions can be achieved. It is essential that the physician taking responsibility for undergraduate teaching within a department takes a leadership role and provides ongoing training and support for both junior and senior colleagues in effective teaching methods.

Whichever teaching method is chosen, evaluation of the process by the participants is an essential part of the quality improvement cycle. Evaluation helps ensure teaching is meeting students’ learning needs, identifies areas where teaching can be improved and provides feedback and encouragement for teachers [13]. Documenting evaluations can form part of a teaching portfolio, which can be used in academic job applications as tangible evidence of a clinician’s and a department’s commitment to and proficiency in teaching. Importantly, from a student’s perspective, being asked to evaluate a teaching session and then seeing the comments acted upon provides a strong sense that their participation is valued and, as a result, may improve the learning process overall.

Some basic pedagogical theory should be considered when choosing and applying methods of teaching: many educators refer to Miller’s triangle of clinical competence [14] and the concept of a spiral curriculum [15] when designing curricula. Figure 24.4.1 is a schematic representation of how emergency medicine as a subject could ideally progress through a 5-year course utilizing these theories of curriculum design. Most departments will only be in a position to offer clinical exposure in the final years of the course, but much progress has been made across the region in penetrating all years. The following delivery methods could be used in this framework to deliver a comprehensive and effective emergency medicine curriculum.

Lecture based

Lectures can be delivered at any stage of the medical course but, to maximize their effectiveness, they need to be developed in an integrated fashion and linked to other components of the course. Emergency medicine can be used effectively as a vehicle to illustrate biomedical science concepts to junior medical students [16]. Case-based learning is a popular method to use in this setting, as learning objectives and concepts can be illustrated in a ‘real-world’ setting. For example, rather than delivering a lecture on ischaemic heart disease, an emergency medicine lecture would be entitled ‘I’ve got pain in my chest’ and the lecturer would engage with students to create a genuine feel for this common emergency presentation. The content would need to be modified depending upon the seniority of students, for example, junior medical students would use the case as a reference point to illustrate anatomy and physiology, while more senior students may use the same scenario to learn about clinical decision making and evidence-based medicine.

Lectures need not be didactic and overloaded with content – a good lecture should be an efficient and entertaining means of effectively transmitting information to large groups. In general, lectures should add value. There is little point simply repeating content from a text, as students can gather the information themselves either in their own time or by using information technology during a boring lecture. In this sense, prospective lecturers should remind themselves of the qualities of an effective educator: expertise in the subject area, enthusiasm for the topic and the task, and capacity to engage the learners [17]. By utilizing these qualities, educators can turn a lecture into a valuable learning experience. Lecturers should have notes pre-prepared and available for students and be prepared for the fact that most will have mobile devices open while the lecture is taking place, will be busy annotating and linking to other resources and may not appear to be giving the lecturer their undivided attention. These are the principles of blended learning, and they will be a key part of education in the twenty-first century. Recording lectures on the university’s learning management system allows for later review and discussion.

Tutorials and small-group learning

Tutorials are small group sessions, with opportunities for interaction and reflection. This model of teaching is well suited to emergency medicine, as individual cases and experiences can be presented and discussed in a comfortable and safe environment. The learners can lead the discussion and take the topics into new and previously unconsidered areas. Nevertheless, providing a structure to the tutorial will help ensure that the time is spent wisely and learning opportunities are maximized. These are usually easily implemented in a department, as they can be integrated with other departmental activities and can run independently of any broader curriculum. This is often the only way that the specialty can deliver its core curriculum in a school without a formal emergency medicine presence. Another pragmatic way to utilize the emergency patient population and promote the department as a place of learning is to work in partnership with other disciplines who can access the department and utilize the patients and the physical space for teaching.

Web-based

This is growing in popularity as schools rely more on information technology to deliver content and this is occurring at the same time that emergency physicans worldwide are taking a leading role in developing resources and promoting the role of social media and other online resources for teaching and clinical care. At a basic level, bulletin boards, web logs (blogs) and e-mail are useful ways to maintain regular communication with students and to distribute journal articles and policies and orientation manuals can be posted online [18].

However, with faster Internet connections and a new generation of students increasingly utilizing mobile learning devices, such as smartphones and tablets, new opportunities are emerging with applications, podcasts, social media and e-books playing increasingly prominent roles in education at all levels. Specific details are provided in the next chapter.

Work-based

This is the original method of medical student education: at the bedside of the patient. Medicine has been taught this way for thousands of years and reinforces the point that medical students are essentially apprentices in a trade. Emergency medicine excels in this area because of the broad range of experiences on offer in a department. Challenges exist, as not all students will be exposed to the same conditions during a rotation. Achieving a uniform experience for students is difficult [19] and so workbooks have been developed to guide students through their rotation, alerting them to the broad range of undifferentiated conditions which regularly present. Utilizing junior staff can be helpful in the education of medical students: pairing a student with a resident or registrar allows the students to see how a doctor works and it involves junior doctors in teaching at an early stage of their careers. It helps with rostering, in that students can be allocated to medical staff with a pre-existing timetable. Medical schools offer clinical academic titles to doctors involved in teaching and all staff should be encouraged to apply for such titles.

Teaching by the bedside is an important activity and opportunities abound for clinical teaching. Clinicians being aware of a broader curriculum can be of assistance, as it can be difficult to think on the spot when confronted with a ‘teachable moment’. Some guidelines exist to maximize the value of bedside teaching and the well-developed principles of ‘set, dialogue and closure’ [20] are explained and listed with an example in Table 24.4.5.

Table 24.4.5

Planning a teaching episode

Concept	Components	Example in practice
Set	Roles – trainers, learners, patients Objectives – what are they going to learn? Linkages – to other learning events Environment – seating, lighting, distractions	Gather the students in a quieter part of the department where distractions will be minimal and make it clear what the session is about: ‘I’d like to talk about ways we assess headaches in the emergency department’
Dialogue	Questions –– use often Understanding Eyes – two-way contact Stimulation – make it interesting Timing – finish on time	Check what the students know about the topic and ask an open question to start, e.g. ‘What are the worrying signs of a headache?’ Encourage discussion, use first names in the discussion
Closure	Review – ask for questions, check understanding Eyes – contact with learner Summary Termination	Summarize the discussion, check that the students have understood it, terminate with a comment (e.g. ‘Thunderclap headaches are a feature of subarachnoid haemorrhage and later we’ll talk about the role of a lumbar puncture’)

You have just assessed a young male with a severe headache. You realize that this is an ideal teaching opportunity for the medical students present.

Simulation

Simulation is a growing field which has been embraced by emergency physicians and the Australasian College for Emergency Medicine. A large knowledge base has been developed and, as such, it will not be discussed at length here. However, the main barrier to utilizing simulation for undergraduate teaching is cost and the available time of emergency physicians. Fortunately, universities are starting to recognize the value of this method of teaching and opportunities are being created, with simulation utilizing people factors and the principles of interprofessional learning being integrated into curricula at all levels.

Clinical skills teaching

Emergency medicine has long had a reputation among students for ‘being the place where you get to do useful things’. While proponents of the specialty as an academic discipline are keen to promote the other features of emergency medicine in an educational setting, this statement is still undoubtedly true. Many skills can be taught in the ED or a skills laboratory and emergency physicians are ideally placed to teach them. Whether it is junior medical students examining patients for the first time or learning practical skills, such as venesection and suturing, emergency physicians have a lot to offer in this regard. Like most teaching, there are useful techniques that can be employed to improve learning [21].

Assessment principles

Assessment should be considered as a tool which drives learning and should be developed in parallel with the curriculum rather than considered at the end. It is essential that the appropriate form of assessment be matched to the subject matter. Assessment tools selected should be valid, reliable and practical and have an appropriate impact on student learning [22]. For instance, when assessing competency in advanced cardiac life support, it would be more valid to use a practical-based assessment process, such as an observed objective structured clinical examination (OSCE) rather than a written examination. Figure 24.4.2 provides a graphical representation of matching assessment processes to skills and knowledge. A large number of assessment methods exist and educators should possess at least a basic understanding of their use and application. It is essential to understand that all universities have rules which govern the assessment of students and failure to adhere strictly to these rules exposes a department to academic appeals and complaints of unfairness and bias. Emergency physicians need to become intimately involved in examination processes throughout the course so that the speciality is taken seriously by students and to ensure that appropriate and realistic emergency conditions and scenarios are presented.

Likely developments over the next 5–10 years

Emergency medicine will continue to play a significant role in medical student education and is poised to make greater contributions in coming years. This will occur both by design and necessity: as described, the increase in student numbers is coinciding with the growth and maturation of the specialty in Australia and New Zealand. Emergency medicine will continue to expand throughout medical curricula rather than being the practice-based pre-intern term it currently occupies in the latter years of most medical courses. A recent shift in focus in the tertiary sector towards teaching ability rather than purely a research output will create opportunities for emergency medicine to gain a stronger foothold in universities. Teaching programmes will expand to deliver material, not just unique to emergency medicine, but the specialty will be opportunistic and be called upon to teach where significant gaps exist at an undergraduate level. In many universities, there is no academic presence in surgical subspecialties, such as ear, nose and throat, ophthalmology and orthopaedics. It will be left to emergency physicians to teach students the basics of these specialties, just as we currently manage many common acute conditions in these areas without specialist input.

It is now time for the specialty to move beyond just the provision of training in acute medicine as envisaged by the landmark Macy report in 1994 [23]. The specialty is developing its own body of knowledge and curriculum in important but under-represented areas of medical education, such as clinical decision making, toxicology, medical error and health systems design and management. The management of elderly patients and end-of-life decision making is becoming a significant part of most emergency physicians’ practice. Hence, emergency physicians need to take a leading role in the development and delivery of curricula in these areas. There is much to suggest that the increased sub-specialization of medicine has led to fragmentation of the health system, with the subsequent inability of society to achieve coherent and sustainable outcomes in health policy. Emergency medicine as a specialty has the opportunity to take a leading role in training doctors and other health professionals capable of understanding the key challenges facing the health system in the 21st century.

24.5 Postgraduate emergency medicine teaching and simulation

Assessment and performance appraisal for emergency medicine training

Assessment in medical education is a complex issue [10]. No single assessment format can adequately measure performance across all domains of emergency medicine practice. Within the specialty there is considerable international variation in the domains of performance formally assessed, the definition of ‘professional competence’ required and in the standardization of assessment processes undertaken.

In-training assessment by clinical supervisors is a core element in most programmes, but this may be provided by one designated supervisor of training or many clinical supervisors in a group-based assessment. Literature suggests that in-training assessment is a valid tool (i.e. measures the right thing), but the potentially subjective nature of supervisor assessments and recall bias can decrease the reliability of assessment [11].

Most training programmes also have formal examination components, generally developed and administered externally by a national training body. A variety of formats exists, including multiple-choice questions, written tests, structured interviews and clinical examination vivas.

Workplace-based assessment (WBA) is becoming more prevalent. This includes formats such as mini-CEX (clinical evaluation exercise) and DOPS (direct observation of procedural skills) in which trainees are directly observed and assessed in a clinical encounter and given immediate feedback. WBAs are valid and reliable if sufficient assessments are undertaken, but resource-intensive and challenging in implementation [12].

Other contemporary assessment tools include clinical simulations, portfolios, standardized patients and multisource ‘360 degree’ feedback assessment. Patient care quality outcomes have been suggested as an assessment tool [13]. These formats support the trend toward specific assessment of communication and professionalism domains, which mirror contemporary shifts in curricular content.

Faculty development in emergency medicine

Many emergency physicians are enthusiastic clinical teachers. However, clinician educators also require specific skills and preparation for their teaching role. Training for educators in emergency medicine might include Masters level courses, short workshops or institution-based group professional development activities. These courses typically cover topics such as curriculum development, teaching and learning processes and assessment and feedback skills.

Programmes are more formally developed in the USA, where a number of teaching fellowships exist in emergency medicine and where the Society for Academic Emergency Medicine (SAEM) has published a Faculty Development Handbook[14]. These initiatives have been reinforced by the emergence of ‘clinician educator tracks’ in academic institutions to provide an academic career structure for clinical teachers.

Continuing medical education (CME)

There is a societal expectation in developed countries that physicians maintain their skills and competence to practice. Australasian emergency physicians are required by the Medical Boards of Australia and New Zealand to demonstrate participation in a continuing professional development programme accredited by the Australian Medical Council. Internationally, the nature of CME requirements vary, but most require periodic assimilation of a portfolio of attendance at conferences and workshops, together with demonstration of participation in clinical practice, teaching, quality assurance activities, research and other special interests. Some jurisdictions require update examinations.