A Curriculum for the Specialty of Emergency Medicine in Europe

Roberta Petrino
European Journal of Emergency Medicine

The European Society for Emergency Medicine (EuSEM) incorporates a federation of 24 European National Societies of Emergency Medicine (EM) through which more than 15 000 physicians are represented. In Europe, the specialty of EM has made remarkable progress during the last 7 years. In 2001, the European Doctors' Directive on the recognition of professional medical qualifications included only the UK and Ireland as recognizing the specialty, but more recent directives (European Directives 2005/36/EC and 2006/100/EC) now list nine European Union nations under the heading of Accident and Emergency Medicine, the name by which EM was formerly known in the UK and Ireland. Other countries in Europe have more recently implemented a 5-year training programme as required by the Doctors' Directive or have developed a 2-3-year programme for training in EM as a supra specialty.

European medical specialties are represented in Brussels by the Union Européenne des Médecins Spécialistes (UEMS), a non-governmental organization promoting quality and standards of training with the purpose of harmonizing care and promoting free movement of doctors within the European Union.

A medical specialty listed in the Doctors' Directive as being recognized in more than one-third of European Union member states can seek the establishment of a separate section within UEMS. EM currently falls just short of that requirement, but after a request by EuSEM, UEMS established a multidisciplinary joint committee (MJC) for EM 3 years ago. This committee includes the Secretary General of UEMS, several EuSEM representatives and a representative from each of the following UEMS sections: Internal Medicine, Anaesthesiology, General Surgery, Orthopaedics and Traumatology, Geriatric Medicine, Paediatric Medicine and the Permanent Working Group of European Junior Doctors.

The recommended content and format of a core curriculum for EM were published earlier in this journal in December 2002 [¹]. This document was discussed during early meetings of the UEMS MJC (EM) and it was decided to revise and enlarge the curriculum to reflect developments in the specialty and recent educational principles. EuSEM therefore established a Task Force with a representative from each of the national societies included in the Federation at the Fourth European Congress on Emergency Medicine in September 2006.

The first meeting of the Task Force was held in Novara, Italy, in February 2007 followed by four further meetings up to April 2008. The final draft of the curriculum was the main agenda item at an MJC (EM) meeting in Brussels the following month.

The document starts by distinguishing the specialty of EM from the emergency medical care, which is within the province and expertise of medical practitioners in many other specialties. It confirms the EuSEM policy statement that EM is '… a medical specialty based on the knowledge and skills required for the prevention, diagnosis and management of urgent and emergency aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioural disorders. It is a specialty in which time is critical.' The essential features of a clinical specialty include a unique field of action, a defined body of knowledge and a rigorous training programme. EM has a unique field of action, both within the emergency department and the community, and the revised curriculum document not only incorporates both the relevant body of knowledge and associated competencies, but also establishes the essential principles for a rigorous training programme.

The second part of the document identifies the six core competencies expected of an emergency physician: patient care, which includes the principles involved in the provision of emergency care to an unpredictable number of undifferentiated patients such as triage, primary assessment and stabilization, secondary survey and clinical decision making, documentation and disposition; medical knowledge and clinical skills (see next paragraph); communication, collaboration and interpersonal skills, which recognize that EM is practised in a difficult and challenging environment with the need for effective communication not only with patients but also with their relatives, with professional colleagues and other care providers and even with the mass media; professionalism and other ethical and legal issues, which include professional behaviour and attributes as well as many important issues such as the competent patient, informed consent, abusive relationships and DNAR (Do Not Attempt Resuscitation) orders; organizational planning and service management skills, which include the competencies necessary to enhance the safety and quality of patient care and the work environment; and finally, education and research, which recognize that emergency physicians must develop skills as effective teachers and be able, at least, to critically review research studies and incorporate relevant findings into clinical practice.

The next and largest part of the curriculum gives further detail about medical knowledge and clinical skills. The Task Force considered the merits of defining the core medical knowledge relevant to the unique environment of an emergency department in accordance with the traditional system-based classification or by reference to the wide variety of symptoms with which a patient may present. It was decided that both approaches should be incorporated and there are separate sections on 'System-Based Core Knowledge' and 'Common Presenting Symptoms'. A further chapter entitled 'Special Aspects of Emergency Medicine' includes topics such as disaster medicine, prehospital care, analgaesia and sedation, toxicology problems in the elderly patient, psycho-social problems, violence and abuse, environmental emergencies and injury prevention. The core clinical procedures and skills that an emergency physician is expected to acquire during training are also outlined.

The last part of the document gives guidelines for the structure and duration of training, the approval of training centres, the selection of trainers and trainees and the evaluation of training programmes. This part is based on the standards of the World Federation for Medical Education for Quality Assurance for Postgraduate Medical Education in Europe [²], and of the UK Postgraduate Medical Education and Training Board for Curricula and Assessment Systems [³], as well as including recommendations from the UEMS Charter on Training of Medical Specialists in the European Community [⁴].

During the last few months, the final draft of the curriculum has been presented to the EuSEM Council, the Presidents of the Federation of European National Societies of EM and the MJC (EM) of UEMS with requests for amendments and approval. It was officially accepted as a EuSEM document during the Fifth European Congress on Emergency Medicine held in Munich in September 2008 [⁵]. The spirit of multinational cooperation, which enabled this complex document to be developed and agreed within a period of just 15 months, reflects the harmony that links emergency physicians across Europe. It is hoped that the core curriculum will now be translated as for national use and adapted locally as appropriate to become a document, which can be used by all European countries seeking to train future emergency physicians.

Two outstanding needs remain: to consider the development of standards for the accreditation of training centres and training programmes, and to consider the development of a European examination to recognize successful completion of EM training. These would help to achieve one of the main goals of EuSEM, which is the harmonization of the quality of training in EM across Europe. One of the most immediate EuSEM proposals is the establishment of a European School of EM to develop training courses to complement the core curriculum. This will doubtless prove to be a challenge, which may be as difficult, but also as fulfilling, as developing the curriculum has been.