Response to "Creating Consensus: Revisiting the Emergency Medicine Scholarly Activity Requirement".

Dear WestJEM Editorial Board:

As representatives of the Emergency Medicine Residents’ Association (EMRA), the Council of Residency Directors in Emergency Medicine (CORD), the American College of Osteopathic Emergency Physicians - Residents and Student Organization (ACOEP-RSO), and the American Academy of Emergency Medicine - Residents and Students Association (AAEM-RSA) we write in response to “Creating Consensus: Revisiting the Emergency Medicine Scholarly Activity Requirement.”1 This paper presents the outcomes of efforts by the Society of Academic Emergency Medicine’s Research Directors Interest Group to understand emergency physicians’ attitudes and opinions on resident scholarly activity. We applaud the authors for their work on this challenging topic, and the editors for bringing it forward for discussion. However, we have some reservations about applications of its conclusions.

In emergency medicine (EM), our Accreditation Council on Graduate Medical Education (ACGME) Review Committee has granted wide latitude to programs when defining scholarly activity.2 A previous survey of EM programs found that a majority of program directors cited curriculum development, review articles, and lectures as ways in which residents adequately fulfill the scholarly activity mandate.3 Such activities were considered scholarly activity by the ACGME in the past,2 and maintained with the recent update to the Common Program Requirements, which were revised to mirror Boyer’s Model of Scholarship including “discovery, integration, application, and teaching.”4,5 The ACGME includes activities such as “grants,” “creation of curricula,” “electronic educational materials,” and “contribution to professional committees...or editorial boards”4 when defining faculty scholarly activity. These broad parameters encompass the spectrum of scholarship that exists in academic departments and embraces evolution, growth, and innovation in education. Kane et al. seeks to modify these requirement by suggesting that scholarly activity solely focus on the instruction of residents in scientific inquiry, and exposure to the mechanics of research. This change would narrow the definition of scholarly activity beyond what is currently accepted by the ACGME, and such an interpretation would preclude the use of national leadership and curriculum design for fulfillment of the scholarly activity requirement. While we appreciate the authors’ perspective, their scope of scholarly activity is of a more traditional research model and not of scholarship, which includes academic development and contributions. This would fall short of providing diverse opportunities to residents for how they use scholarly activity to grow their careers and our specialty.

Kane et al. made significant effort to have numerous opinions included in their consensus definition for scholarly activity. However, despite these efforts, CORD was absent from their in-person meeting. While CORD’s members responded to the survey, no subgroup analysis was performed, so viewpoints of the subset of emergency physicians who have the most direct contact with residents and their scholarly activity are not specifically outlined in this paper. This is a significant limitation to the consensus that these authors seek.

We also feel that the methodology used to interpret the survey fails to describe consensus. The cut point chosen to define consensus of 3.33 on a 4-point Likert scale makes it possible for 100% of respondents to “somewhat agree” with a statement and for this to not represent consensus. It also suggests that people who “somewhat agreed” with an option were actually voting against consensus on that item. The American Journal of Public Health recommends that, when building consensus, “if agreement of at least two thirds of participants can be reached...consensus is established.”6 This recommendation is more closely represented by a cut point of 2.66, which could have allowed case reports, curriculum design, or blog posts to count toward a consensus definition. Thus, the items included in their definition of consensus (and more importantly, those left out) cannot be meaningfully interpreted.

EMRA, CORD, ACOEP-RSO, and AAEM-RSA support a broad definition of scholarly activity that extends beyond the points proposed by Kane et al. We encourage the reader to consider the breadth of activity that contributes to the scholarly advancement our speciality when deciding what to require for trainees. There is real value in work which contributes to the discovery, integration, application, and teaching of emergency medicine, and we hope that the ACGME EM-RC will continue its practice of broadly defining scholarly activity, and not limit the future of this vibrant speciality.

Dear WestJEM Editorial Board:

We thank Pasichow et al. for taking the time to both read and comment on the consensus work reported in Kane et al.1 Foremost, our work was not intended to remove from individual program directors the ability to locally define scholarly activity. Program directors are already guided by a list of minimum expectations that the Review Committee for Emergency Medicine (EM) has labeled as “examples of acceptable resident scholarly activity.”2 Some programs will strive to achieve more than the minimum and prepare their residents for a higher level of scholarship and research. Pasichow et al.’s well-presented comments on the nature of scholarship are discussed in greater detail in an article published in the WestJEMby Ander and Love.3 The article provides information on how to apply Boyer’s model, and provides both standards and a model to determine if a project meets a “test of scholarship.”

Our stated goal was to identify best practices for the scholarly requirement from as broad a perspective as possible. The original work dates back 20 years, and represents the specific views of research directors at that time.4 Medicine in general and EM in particular have evolved since then. Current Accreditation Council for Graduate Medical Education (ACGME) requirements include emerging emphasis on quality improvement.5 In response, our work has added quality improvement to a list of best practices for the scholarly requirement. Pressures from demographics and delivery of care continue to change the practice of EM.6 When combined with emerging technologies, our collective professional view of scholarship will also need to evolve. To address the influence of continued change in EM, there may be value in regularly revisiting the scholarly activity requirement on a more frequent basis. Both the upcoming changes to the ACGME Common Program requirements and their application by our Review Committee may impact when it is best to next revisit the scholarly requirement.7

In the end, stimulating dialogue such as that provided by this letter to the editor is the greatest opportunity for the application of our work. Hopefully, some of the resultant discussion will occur at the level of individual residency programs within the ACGME-required “Self Study” process.8 As each program sets its individual “program aims” and performs “strategic assessment” to “take the program to the next level,” our work and discussion such as this will hopefully be of value.