The Future of Emergency Medicine Education

A conversation with Mike Gisondi, MD, vice chair of education, and Sara Krzyzaniak, MD, associate vice chair and director of the emergency medicine residency program in the Stanford University Department of Emergency Medicine.

As the pace of change in medicine accelerates, how do we ensure emergency medicine trainees have the skills to adapt?

Gisondi: An emergency physician is going to manage new or unusual cases throughout their career, much more frequently than other specialties, so we must teach our trainees to be adaptive learners and problem solvers, and prepare them for the outlier cases. Adaptive learners are efficient and effective at solving problems they’ve rarely or never seen before. They are not necessarily the smartest in the class, but they’re very good at learning and solving problems.

To train for the unexpected, trainees need to see as many variations of common cases as possible, in advance, to build the broadest possible knowledge base. Then they can call upon that foundational knowledge and use it differently to solve new problems. But to do so, they also have to be flexible and change how they approach things, either diagnostically or therapeutically, based on the context.

We use simulation to train residents on cases not often seen in clinical practice. We also use hypothetical questions on shift, such as: ‘ Jane is presenting with chest discomfort — what if Jane was 80 years old, or a man, or had diabetes.’ We change important details when discussing patients with a resident and run through a number of case variations quickly to build their heuristics.

Krzyzaniak: I agree — the most important thing we can teach our residents is how to be adaptive and how to plan their learning when they encounter something new.

Our faculty members provide feedback to residents based on observable behaviors and areas for improvement after every single shift, both verbally and using an app. The feedback mechanism tells residents, ‘Here is your knowledge gap, and here’s where I want you to be tomorrow, next week, next year.’ We train our residents to look for those gaps as well. Then in a guided self-assessment with their coach, they create a learning plan specific to their needs.

What does precision career development mean at Stanford?

Krzyzaniak: We give our residents early opportunities for niche development. We added career development time to the intern year curriculum after we realized that the second year was too late to fully explore electives and make meaningful connections with our faculty in their niche development.

Now, interns are given two weeks to select and explore two of thirteen introductory areas — to connect with our faculty and fellows, learn about their projects, attend meetings, and see what it would be like to have a career in global health or in social emergency medicine, for example. In the background, we also have our research curriculum running, so residents simultaneously learn about the principles of scientific inquiry.

With that foundation, in their second year, residents select from over 100 electives they can pursue in depth. And every year residents develop something new — most recently, we added electives in palliative care, medical humanities, and climate change.

Our faculty provide mentoring for residents in their areas of expertise and faculty who completed specialized training are assigned a cadre of residents to coach throughout the year.

How do you foster physician-researchers when residency is crowded with clinical practice and didactics?

Krzyzaniak: We recently introduced longitudinal elective time for research. This option allows residents to spread their elective time over a year, effectively resulting in clinical shift reduction to complete their research. This model is also beneficial for residents working on community-based projects where trust and partnerships take time to build.

We also created the Alumni Scholarship Fund with generous donations from our residency program alumni. Residents can apply for funding for courses or activities. Our first awardee, Nabiha Nuruzzaman, MD, used the Alumni Scholarship to support her tuition as a Health Equity Scholar with the Cambridge Health Alliance. As part of this program, she partnered with local community organizations in Navajo Nation to develop an elective for providers to learn about and address issues of environmental justice and health.

How can residents learn to incorporate social drivers of health and address inequities in care?

Krzyzaniak: This is crucial. We know every patient is different, and every disease process looks different based on the person, for many reasons.

 Our didactic curriculum includes time for health equity rounds and social emergency medicine. Our case-based discussions explore how social drivers impact patients. We have an ED complex care team that works with patients to address social drivers that lead to repeat visits. Our ED also has 24/7 social work and case management, two substance use navigators, and interpreters to help provide bedside patient-centered care.

Gisondi: Just as a phenotype is expressed differently in different environments, patients manifest conditions differently. Our specialty is supposed to take care of anyone, anytime, from any background, regardless of the ability to pay. That’s something we’re all very proud of, but putting that ethos into practice every day can be challenging.

We have such a wide diversity of socioeconomic and cultural backgrounds here in the Bay Area. Someone from East Palo Alto, which is under-resourced, will manage their diabetes differently than someone who lives in more affluent Marin County. We train our residents to understand that as clinicians, we have to be aware of these drivers and flex the management of a case based on the patient’s social realities and the roadblocks they might be facing.

Based on the number of unfilled entry-level positions in 2023 Match, what needs to change in emergency medicine residency training?

Krzyzaniak: I think there were multiple contributing factors in the 2023 Match when half of the programs in the country didn’t fill in the first round.

Our specialty was hurt by a workforce study that projected a surplus of emergency physicians. We now know that those projections used questionable assumptions, but deans of medical schools and career advisors may not know that. COVID-19 had an impact as well. It was a scary time to be in emergency medicine and the pandemic contributed to burnout and impacted the decisions of students considering the specialty.

Regardless of the reasons though, the 2023 recruitment results should be a warning call for all of us. We need to paint a complete picture of emergency medicine for medical students. It’s a wonderful specialty! We need stronger representation at the medical school level. And we need to bring more medical students into the ED. When we do, they say, ‘This isn’t at all what I expected. This is fulfilling and exciting.’ But they’re not getting enough exposure to see that.

Does the patient population at Stanford impact the training residents receive?

Krzyzaniak: Our residents see a tremendously diverse patient population in part because they work at three distinct sites — county, community, and tertiary academic hospitals. Even within Stanford Hospital ED, we have incredible diversity. On any given shift, I can walk from room to room and see the complex medical patient that Stanford is known for; the otherwise healthy patient presenting with an acute complaint; and the undomiciled patient with substance use disorder who’s been there for the third time that day without acute medical needs but instead many social needs. We are located in the heart of Silicon Valley, which affords us many resources and innovation; but we also have a diverse and large patient population that is financially insecure because of the high cost of living.

Before coming here, I never discharged someone to their RV parked three blocks away. Now I’m trying to figure out what I can do for this person who has cellulitis but doesn’t actually have running water in their RV and needs antibiotics but doesn’t have a place to elevate their leg.

Gisondi: There’s a long-standing misconception that Stanford is an ivory tower ED with wealthy patients and low volumes. But our census actually places us as one of the busiest EDs in the country, certainly among academic programs. And twenty percent of patients we admit from the ED come from more than 50 miles away.

Are you training residents to use AI in the ED?

Krzyzaniak: We educate residents on the pros and cons of AI in medicine as part of our didactic curriculum. And our faculty are doing research using AI and writing about AI, so our residents have opportunities to learn more. But I don’t feel AI is yet a part of everyday emergency medicine. A lot of our conversations are looking to the future when AI is more embedded in clinical practice.

Gisondi: If you ask this question again 12 months from now, we will have much more robust examples. Things are moving so quickly in that space — this time last year, the phrase “generative AI” was not a commonly used term.

In education, there was an initial fear students would use AI to fabricate essays or for malicious purposes. But we have to get past those fears of new technologies — in this case, there are so many substantive ways that we can use AI to support learning. I am planning a new faculty development workshop series on AI applications for clinical practice, teaching, research, etc.

There’s the issue of utilizing AI effectively, but also the question of what value the physician will have in the future. Trying to predict all of that now is challenging. You’re training people for a job that doesn’t really exist yet. But it gets back to adaptive learning. If we give residents the skills to learn about something that they haven’t yet seen, we prepare them to evolve as medicine evolves.

What does the future of emergency medicine training look like?

Gisondi: The emergency medicine care delivery model is evolving before our eyes. The ways that patients access the healthcare system for acute care is changing — many will present to the ED, but others will use video visits, home-based care options, or innovative channels that our faculty are just now building. We are moving to a care delivery model that’s more progressive and meets patients where they’re at. We will better facilitate healthcare access in ways that aren’t burdensome to patients.

Our residents need to learn how to train in those environments. For example, we will soon offer residents clinical experiences using emergency medicine telehealth.

Krzyzaniak: Emergency medicine is very different from what it was in the 1970s when the first EM training programs started. The medicine is more complex. The technology is more complex. And we’re asked to serve many roles for our patients: primary care physicians, specialists, case managers, psychiatrists, et cetera.

We also must understand how social drivers of health impact patient outcomes; master the art of communication to successfully interface with other medical teams; and learn to be efficient in the face of steadily climbing ED volumes at Stanford. And we need to be prepared to take emergency medicine outside of the ED walls to meet the needs of all of our patients.

Our training needs to reflect all of these new roles we must play, in addition to providing outstanding clinical care.

Spring 2024