Education The 2022 Model of the Clinical Practice of Emergency Medicine

Laura Oh, MD , ‡ , ∗∗∗ Viral Patel, MD , ††† Loren Touma, DO , ‡‡‡ , §§§ Melissa A. Barton, M.D. , ∗ and Julia N. Keehbauch ∗, 2022 EM Model Review Task Force; Melissa A. Barton, M.D. ∗, and Julia N. Keehbauch ∗ , American Board of Emergency Medicine ∗ American Board of Emergency Medicine, East Lansing, Michigan, ∗American Board of Emergency Medicine, East Lansing, Michigan, † Summa Health, Akron, Ohio, ‡ American College of Emergency Physicians, Irving, Texas, §Medstar Washington Hospital Center, Georgetown University School of Medicine, Washington, District of Columbia, ||Society for Academic Emergency Medicine, Des Plaines, Illinois, ¶Duke University School of Medicine, Durham, North Carolina, #New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, ∗∗Accreditation Council for Graduate Medical Education, Chicago, Illinois, †† Emergency Medicine Residents’ Association, Irving, Texas, ‡‡ Hennepin County Medical Center, Minneapolis, Minnesota, §§American Academy of Emergency Medicine, Milwaukee, Wisconsin, ||||Sentara Norfolk General Hospital, Eastern Virginia Medical School, Norfolk, Virginia, ¶¶Council of Residency Directors in Emergency Medicine, Irving, Texas, ##Virginia Commonwealth University School of Medicine, Richmond, Virginia, ∗∗∗Emory University, Atlanta, Georgia, ††† UMass Chan Medical School, Worcester, Massachusetts, ‡‡‡ American Academy of Emergency Medicine Resident and Student Association, Milwaukee, Wisconsin, and §§§Jefferson Health Northeast Emergency Medicine, Philadelphia, Pennsylvania Reprint Address: Julia N. Keehbauch, American Board of Emergency Medicine, 3000 Coolidge Road, East Lansing, MI 48823


Overview
Emergency medicine has a scientifically derived and commonly accepted description of the domain of its clinical practice.That document, The Model of the Clinical Practice of Emergency Medicine (EM Model), was developed through the collaboration of the following six organizations: American Board of Emergency Medicine (ABEM), which is the administrative organization for the project; American College of Emergency Physicians (ACEP); Council of Emergency Medicine Residency Directors (CORD); Emergency Medicine Residents' Association (EMRA); Residency Review Committee for Emergency Medicine (RC-EM); and Society for Academic Emergency Medicine (SAEM).Development of the EM Model was based on an extensive practice analysis of the specialty.The practice analysis relied on both empirical data gathered from actual emergency department visits and several expert panels ( 1 ).The resulting product was first published in 2001 and has served successfully as the common source document for all emergency medicine organizations ( 2 , 3 ).One of its strengths is incorporating the reality that emergency medicine is a specialty driven by symptoms, not diagnoses, that require simultaneous therapeutic and diagnostic interventions.
The task force that developed the EM Model recommended that a new task force, composed of representatives from all six organizations, be formed every 2 years to assess the success of the document in accomplishing its objective of supporting the ongoing development of the specialty of emergency medicine; to consider alterations to the EM Model suggested by the collaborating organizations; and to recommend changes to the six sponsoring organizations.The initial 2-year review occurred in 2003, with representatives from each of the six organizations suggesting changes and reporting how their respective organizations had used the document.The initial 2-year update was published in Annals of Emergency Medicine and Academic Emergency Medicine in 2005 ( 4 , 5 ).Subsequently, a task force met every 2 years to review the EM Model and recommend changes (6)(7)(8)(9)(10)(11)(12)(13).In 2013, a seventh organization, the American Academy of Emergency Medicine (AAEM), was added as a collaborating organization.In 2014, the collaborating organizations made the decision to review the EM Model on a 3-year review cycle, beginning in 2016.The 2016 update was published in the Journal of Emergency Medicine in 2017 ( 14 ).In 2019, the American Academy of Emergency Medicine Resident and Student Association (AAEM/RSA) was added as an eighth collaborating organization.The 2019 update was published in the Journal of Emergency Medicine in 2020 ( 15 ).
On the recommendation of the 2019 EM Model Review Task Force, three working groups were formed in 2021 to focus on ultrasound, cutaneous disorders, and evolving trends in health care.The product of these working groups, along with the results of a job analysis conducted in 2022, helped inform decisions made by the 2022 EM Model Review Task Force related to these areas.Numerous changes occurred with the 2022 review, including expansion of the ultrasound section of Category 19, Procedures and Skills Integral to the Practice of Emergency Medicine.Category 20, Other Core Competencies of the Practice of Emergency Medicine, was significantly revised to provide more clarity regarding patient-centered care.In addition, the task force recommended that a work group be convened to review and recommend updates to the acuity definitions prior to the 2025 EM Model review.This article provides a brief review of the original EM Model, along with the changes to the EM Model recommended by the 2022 EM Model Review Task Force.A summary of all 2022 changes and an update on current uses of the EM Model by the eight collaborating EM organizations are also included in this article.

The EM Model
The EM Model is a three-dimensional description of EM clinical practice.The three dimensions are patient acuity; physician tasks; and a listing of medical knowledge, patient care, and procedural skills.All of these dimensions are interrelated and used concurrently by a physician when providing patient care.The emergency physician's initial approach is determined by the acuity of the patient's presentation.When assessing the patient, the physician completes a series of tasks in collecting information.Through this process, the physician is able to select the possible etiologies of the patient's problem from the listing of medical knowledge, patient care, and procedural skills.Through simultaneous application of all three components, the physician is able to determine the most probable diagnosis and implement a treatment plan for the patient.The three dimensions, as revised in 2022, are included in Tables 1-4 .
The Accreditation Council for Graduate Medical Education (ACGME) requires each specialty to develop outcomes-based milestones for resident performance within the six general (core) competencies (i.e., patient care, medical knowledge, practice-based learning and improvement, interpersonal skills, professionalism, and system-based practice).The six general competencies are an integral part of the practice of emergency medicine and are embedded in the EM Model ( 16 , 17 ).The EM Model is closely aligned with the general competencies, using section headings with similar terminology.
The EM Model is designed for use as the core document for the specialty.It provides the foundation for developing medical school and residency curricula, certification examination specifications, continuing education objectives, research agendas, residency program review requirements, and other documents necessary for the definition, skills acquisition, assessment, and practice of the specialty.In conjunction with the EM Model, these six general competencies construct a framework for evaluation of physician performance and curriculum design to further refine and improve the education and training of competent emergency physicians.The six competencies and the EM Model also form the core of ABEM's continuing certification process.For further information on this process, see ABEM's website at www.abem.org .

Changes to the EM Model
The 2022 EM Model Review Task Force met to consider changes based on the results of a job analysis conducted in January 2022 and input received from the eight collaborating organizations.Each organization was asked to comment on how it uses the EM Model, identify changes in practice or updated evidence, and to recommend changes in the document that would address any deficiencies.The changes recommended by the 2022 EM Model Review Task Force and accepted by the eight organizations are provided in the Appendix.

AAEM
AAEM uses the EM Model as a reference document to identify topics for annual conference programming.

ABEM
ABEM uses the EM Model to define its examination specifications.Each question or structured case used in any ABEM examination is referenced to the EM Model.Every test and examination that ABEM develops is based on a blueprint derived directly from the EM Model.

ACEP
ACEP uses the EM Model primarily as the basis for its educational activities.In addition, the ACEP Academic Affairs Committee uses the EM Model to align programming with academic educational needs.This information is used to develop a comprehensive list of web-based educational resources that can be incorporated into residency curricula.

CORD and the RC-EM
The integration of the competencies into the EM Model meets the program requirements of the RC-EM that the six core competencies are included in residency training.The EM Model is a major tool for CORD and emergency EMRA and AAEM/RSAEMRA and AAEM/RSA use the EM Model as a reference document to identify content at risk for testing on the in-training and certification examinations.SAEMSAEM uses the EM Model as a reference document to identify topics and plan programming.In summary, the EM Model is accomplishing the intended purposes for which it was developed.The 2022 review of the EM Model resulted in significant changes and clarifications, including the expansion of the ultrasound section within Category 19, Procedures and Skills Integral to the Practice of Emergency Medicine.Category 20, Other Core Competencies of the Practice of Emergency Medicine, was also revised substantially to provide more clarity regarding patient-centered care.Several EM organizations are using the EM Model to support the ongoing development of the specialty of EM.The complete updated 2023 EM Model can be found on the websites of each of the eight collaborating organizations.

Table 3 . Physician Task Definitions Prehospital
care Participate actively in prehospital care; provide direct patient care or on-line or off-line medical direction or interact with prehospital medical providers; assimilate information from prehospital care into the assessment and management of the patient.Effectively interpret and evaluate the patient's symptoms and history; identify pertinent risk factors in the patient's history; provide a focused evaluation; interpret the patient's appearance, vital signs, and condition; recognize pertinent physical findings; perform techniques required for conducting the examination.Modifying factorsRecognize age, gender, race, ethnicity, barriers to communication, socioeconomic status, underlying disease, gender identity, sexual orientation, and other factors that may affect patient management.
Diagnostic studies Select and perform the most appropriate diagnostic studies and interpret the results, e.g., electrocardiogram, emergency ultrasound, radiographic, and laboratory tests.Diagnosis Develop a differential diagnosis and establish the most likely diag noses in light of the history, physical, interventions, and test results.Documentation Communicate patient care information in a concise and appropriate manner that facilitates quality care.This includes documentation and medical decision-making variables related to billing, coding, and reimbursement for patient care.

Table 3 . ( continued )
Establish rapport with and demonstrate empathy toward patients and their families; listen effectively and build trust with patients and their families.Identify situations that require individualized communication or shared decision making, such as goals of care, end-of-life care, and palliative options.PrognosisForecast the likely outcome of a medical disease or traumatic condition.

Table 4 . ( continued )
Premature labor (See 18.2.3)X 13.6.3Premature rupture of membranes X 13.6.4Rupture of uterus (See 18.2.4)X ( continued on next page )