Emergency Medicine Curriculum Research Articles

193 Development of Learning Objectives for a Standardized Pediatric Emergency Medicine Curriculum for the African Federation for Emergency Medicine

Few African countries have dedicated emergency medicine training, and none have a pediatric emergency medicine (PEM) program. However, many countries have a high burden of pediatric patients, and as many as 25% of those patients have high-acuity disease. The African Federation for Emergency Medicine (AFEM) is developing an open-access, core curricular package for pediatric emergency medicine to meet this need. Our objective was to implement group consensus methodology to develop learning objectives for this curriculum. A group of PEM and global health experts developed a comprehensive list of objectives based upon a needs assessment conducted in Tanzania in 2017. A second panel of experts met at the African Conference on Emergency Medicine in Rwanda in November 2018 and employed a modified Delphi process to attain consensus regarding the list of objectives. A semi-anonymous format of voting was used to allow for balanced input. Consensus was defined as >70% approval. Any objective not meeting at least 30% approval was immediately removed; an objective meeting 30-70% approval was discussed and edited as needed, and repeat voting determined final approval rate. The objectives were evaluated for appropriateness for 3 previously defined provider groups: (1) out-of-hospital providers, nurses, (2) medical officers, senior nurses, and (3) residents, specialists, consultants. There were 7 voting participants in the modified Delphi process. All Tier 3 objectives (79) met consensus. One objective from Tier 2 was revised under consensus, and one objective was added with consensus agreement to create a list of 42 objectives. Five objectives in Tier 1 did not initially achieve consensus, 4 of which required revisions, for a final list of 30 objectives. A group consensus process resulted in the development of a list of 161 objectives for a pediatric emergency medicine curriculum for multiple levels of practitioners in African settings. These objectives will guide development of the AFEM pediatric emergency medicine curriculum, which will advance pediatric emergency care competency across Africa.

The Extended Supervised Learning Event (ESLE): Assessing Nontechnical Skills in Emergency Medicine Trainees in the Workplace

The contribution of emergency medicine clinicians' nontechnical skills in providing safe, high-quality care in the emergency department (ED) is well known. In 2015, the UK Royal College of Emergency Medicine introduced explicit validated descriptors of nontechnical skills needed to function effectively in the ED. A new nontechnical skills assessment tool that provided a score for 12 domains of nontechnical skills and detailed narrative feedback, the Extended Supervised Learning Event (ESLE), was introduced and was mandated as part of the Royal College of Emergency Medicine assessment schedule. We aim to evaluate the psychometric reliability of the ESLE in its first year of use. ESLEs were mandated for all UK emergency medicine trainees in the final 4 years of a 6-year national training program from August 2015. The completed assessments were uploaded to the Royal College of Emergency Medicine e-portfolio. All assessments recorded in the Royal College of Emergency Medicine e-portfolio database between August 2015 and August 2016 were anonymized and analyzed for psychometric reliability, using generalizability theory. Decision analysis was used to model the effect of altering the number of episodes and assessors on reliability. A total of 1,390 ESLEs were analyzed. The majority (62%) of the variation in nontechnical skills scores was attributable to the trainee's ability. The circumstances of the event (eg, case complexity, workload) accounted for 21% and the stringency or leniency of assessors the remaining 16%. Decision analysis suggests that 3 ESLEs by 2 or more assessors, as currently recommended in the Royal College of Emergency Medicine curriculum, provide an assessment with a reliability coefficient of 0.8. Board-certified-equivalent emergency medicine supervisors are able to provide reliable assessments of emergency medicine trainees' nontechnical skills in the workplace by using the ESLE.

Needs assessment for a formal emergency medicine residency program in southern Madagascar.

IntroductionWorld Health Organization data for Madagascar reveal that the nation's under age five mortality rate is 56/1000, and that its maternal mortality rate is 440/100,000. Malaria, leprosy, plague, and tuberculosis remain significant communicable disease threats. Malnutrition rates are improving but continue to impact negatively on the general health of the Malagasy population, especially in the southern region with its 1.9 million inhabitants. There are no emergency medicine (EM) training programs to serve the southern half of Madagascar, which has a large urban population in Fianarantsoa. This study aimed to assess the need for and potential feasibility of an emergency medicine training program in southern Madagascar.MethodsWe met with the institutional leadership on site at the university hospital in Fianarantsoa. A needs assessment was performed on multiple domains. Domain 1: existing hospital infrastructure and its physical plant and emergency centre (EC) space allotment. Domain 2: existing clinical and technological resources. Domain 3: educational resources and the existing curriculum for EM. Domain 4: medical student educational program and availability of prospective residency candidates. Domain 5: pre-hospital care and emergency medical services.ResultsThe size of the EC is adequate for the current census. Clinical resources are typical of many developing countries, with significant need for technological advancement and support, which we delineate in the body of our paper. There is an existing curriculum in Antananarivo and in Majanga, as well as one available through the African Federation for Emergency Medicine. The medical school in the area is relatively new, with graduating classes numbering approximately 30. There is no organised pre-hospital care system, no 9-1-1 equivalent, and no pre-hospital treatment from within metropolitan Fianarantsoa.ConclusionsWhile the needs assessment indicates substantial need for emergency medicine development in southern Madagascar, the yield (particularly for the metropolitan Fianarantsoa area) would serve the population well.

MP18: Addressing unrealistic expectations: a novel transition to discipline curriculum in emergency medicine

Innovation Concept: Emergency medicine (EM) programs have restructured their training using a Competence by Design model. This model emphasizes entrustable professional activities (EPAs) that residents must fulfill before advancing in their training. The first EPA (EPA 1) for the transition to discipline (TTD) stage involves managing the unstable patient. Data from the University of Toronto (U of T) program suggests residents lack enough exposure to these patient presentations during TTD – creating a disconnect between anticipated clinical exposure and the expectation for residents to achieve competence in EPA 1. Methods: To overcome this gap, U of T EM faculty specifically targeted EPA 1 while designing the TTD curriculum. Kern's six-step approach to curriculum development in medical education was used. This six-step approach involves: problem identification, needs assessment, goals and objectives, education strategies, implementation and evaluation. To maximize feasibility of the new curriculum, existing sessions were mapped against EPAs and required training activities to identify synchrony where possible. Residents were scheduled on EM rotations with weekly academic days that included this novel curriculum. Curriculum, Tool or Material: Didactic lectures, procedural workshops and simulation were closely integrated in TTD to address EPA 1. Lectures introduced approaches to cardinal presentations. An interactive workshop introduced ACLS and PALS algorithms and defibrillator use. Three simulation sessions focused on ACLS, shock, airway, trauma and the altered patient. A final simulation session allowed spaced-repetition and integration of these topics. After the completion of TTD, residents participated in a six-scenario simulation OSCE directly assessing EPA 1. Conclusion: The curriculum was evaluated using a multifaceted approach including surveys, self-assessments, faculty feedback and OSCE performance. Overall, the curriculum achieved its goal in addressing EPA 1. It was well-received by faculty and residents. Residents rated the sessions highly, and self-reported improved confidence in assessing unstable patients and adhering to ACLS algorithms. The simulation OSCE demonstrated expected competency by residents in EPA 1. One limitation identified was the lack of a pediatric simulation session which has now been incorporated into the curriculum. Moving forward, this innovative curriculum will undergo continuous cycles of evaluation and improvement with a goal of applying a similar design to other stages of CBD.

Critical Concepts in Disaster Medicine for Saudi Arabian Emergency Residency Programs: A Delphi Study

Introduction:Saudi Arabia, the largest country in the Middle East, has suffered numerous terrorist attacks and is the location of Hajj, one of the world’s largest annual mass gatherings. Healthcare providers’ pre-incident knowledge and understanding of basic disaster medicine (DM) concepts are crucial for a unified and effective health-system response. Introducing healthcare providers to best practices is a stated vision of the Saudi Commission for Health Specialties. Standardizing DM curriculum taught to physicians during their residency training will assist this goal.Aim:To produce expert consensus on the most critical DM topics for the residency curriculum in emergency medicine (EM) in the Kingdom of Saudi Arabia.Methods:Utilizing a Delphi approach, a panel of Saudi Arabian experts in DM and EM residency directors were surveyed regarding potential DM topics for EM residency curricula. The first round comprised of open-ended questions seeking lists of suggested DM curriculum topics. In subsequent rounds, each participant received a questionnaire asking them to review the items contributed in the first round, summarized by the investigation team. The participants rated each item on a five-point Likert Scale to establish preliminary priorities and added their comments. In further rounds, participants reviewed and prioritized subjects until they reached a consensus of >=80%.Results:The study is ongoing and full data will be available in the new year.Discussion:This expert consensus from major stakeholders can be used to improve the foundation of the DM curriculum. The Delphi Method gives an evidence-based approach to identification and prioritization of subjects, which should be integrated within the Saudi Arabian Emergency Medicine Residency Curriculum. It also can be used as a cornerstone for implementation in other medical education programs across the Kingdom in the future.

Use of Technology to Identify and Cover Underweighted Topics in Resident Conference Curriculum.

Emergency medicine training programs face many challenges in creating and maintaining high quality didactic and asynchronous learning experiences. To address these challenges, our team created two tools. First, we designed the Emergency Medicine Curriculum Assessment Tool (EMCAT) to help program leaders compare their didactic program to the Model of Clinical Practice established by the American Board of Emergency Medicine (ABEM). Second, we created a catalog of free, open-access medical education (FOAMed) resources based on the ABEM Model subcategory. Residency leaders can use EMCAT to identify the underweighted topics in their conference program and then access the resource catalog to find educational content matched to their areas of increased need. To date, five programs have implemented EMCAT and users from over 72 countries have accessed nearly 1,000 resources. Both EMCAT and the resource catalog are available free online.

Emergency Medicine Curriculum Utilizing the Flipped Classroom Method: Environmental Emergencies

Author(s): Bachmann, Daniel; Gartner, Sarah; King, Andrew; Kman, Nicholas; Bowman, Mary Jo; Barrie, Michael

Emergency Medicine Curriculum Utilizing the Flipped Classroom Method: Pulmonary Emergencies

Author(s): Branditz, Lauren; King, Andrew; Kaide, Colin; Mitzman, Jennifer; Ostro, Benjamin; Martin, Daniel; Kman, Nicholas; Bahner, David; Werman, Howard; Thema, Tatiana; Barrie, Michael

Emergency Medicine Curriculum Utilizing the Flipped Classroom Method: Infectious Disease and Immunology

Author(s): Ostro, Benjamin; King, Andrew; Branditz, Lauren; Martin, Daniel; Bachmann, Daniel; Panchal, Ashish; Barrie, Michael

Novel Emergency Medicine Curriculum Utilizing Self- Directed Learning and the Flipped Classroom Method: Hematologic/Oncologic Emergencies Small Group Module

Novel Emergency Medicine Curriculum Utilizing Self- Directed Learning and the Flipped Classroom Method: Hematologic/Oncologic Emergencies Small Group Module

Novel Emergency Medicine Curriculum Utilizing Self-Directed Learning and the Flipped Classroom Method: Neurologic Emergencies Small Group Module

Novel Emergency Medicine Curriculum Utilizing Self-Directed Learning and the Flipped Classroom Method: Neurologic Emergencies Small Group Module

Development, implementation and first insights of a time- and location-independent longitudinal postgraduate curriculum in emergency medicine.

Introduction, background and context: There have been few reports on the implementation of a structured curriculum for emergency medicine, as emergency medicine is not yet an established medical specialty for training in many European countries, including Switzerland and Germany. Because of the non-plannable workload in the emergency setting, common training approaches are often difficult to implement. Need-assessments of emergency medicine trainees commonly identify a need for interactive, time-independent ways of learning that integrate modern forms of knowledge transfer. Methods: In the present study, we assess the local needs of emergency medicine specialists and trainees for a curriculum in emergency medicine and elaborate possible solutions for the implementation of this curriculum, taking into account the special needs in a highly dynamic, unplannable environment, such as an interdisciplinary emergency department. Results: We describe the development of the emergency medicine curriculum on the basis of the six steps proposed by Kern for curriculum development in medical education, as well as the implementation, lessons learned and interval evaluation.Conclusions: The combination of multiple teaching formats, ranging from time- and location-independent solutions such as podcasted lectures to simulation-based training sessions, as well as small-group workshops and skill training sessions, might be a valuable approach to implementing a state-of-the-art curriculum in a busy emergency department.

Continuing the Legacy of Editorial of the First Issue of Journal of Karnali Academy of Health Sciences

Professor Dr MN Marhatta wrote in detail about the 'Milestones of Medical Education in Karnali Academy of Health Sciences' in the first issue of Journal of Karnali Academy of Health Sciences (JKAHS). By the time of this second issue of JKAHS, there has been substantial progress in achieving the goals set and plans put forward by the Academy.
 Two bachelor programs, i.e., Bachelor in Midwifery Sciences (BMS) and Bachelor in Public Health (BPH) studies are going to start from Mangsir 2075. Certified Anesthesia Assistant (CAA) training course is running smoothly. The Academic Council has prepared and the panel of experts has endorsed the curriculum of Masters in Obstetrics and Gynecology (MD), Masters in Orthopedics and Trauma Surgery (MS), and Masters in Anesthesiology and Critical Care (MD). Masters in General Practice and Emergency Medicine (MDGP) curriculum was prepared in the presence of experts of the various subjects, endorsed by the Academic Council of the Academy and submitted to the Nepal Medical Council (NMC) for approval and accreditation. The NMC has already agreed to take the process forward and has decided to visit KAHS for feasibility study and inspection of its preparation.
 KAHS is reasonably prepared to start its first Masters academic program. The Academic Council has appointed two professors in MDGP, one each in Obstetrics and Gynecology, Orthopedics, and General surgery, which is an essential and major asset for starting residency programs in the Academy. As per the criteria set by the NMC, the Academic Council has appointed the faculties in the Departments of Psychiatry and Dermatology, and the departments in Basic Medical Sciences including Anatomy, Physiology, Pharmacology, and Microbiology have been established. The class/ lecture rooms are well set up and the faculties of various department are excited and ready to welcome the first batch of MDGP residents in Jumla.
 There has been huge progress in the field of research and publication as well. The Nepal Health research Council has agreed to permit establishing Institutional Review Committee (IRC) in the Academy, which, we believe, will encourage the faculties and the students to participate in various national as well as locallevel scientific studies and research. There was overwhelming response from the Academy faculties as well as the faculties from various other academic institutes during the call for papers for publication in this journal.
 The future of Karnali Academy of Health Sciences is looking bright as this Academy was established to provide education and health services to the most marginalized people of the country. This Academy is located in a unique geography which has a huge possibility of becoming a unique institute in the field of medical education. And, this journal will continue to publish cutting-edge research and studies done in this Academy and elsewhere in the country.

TF-4 The Emergency Medicine Curriculum Assessment Tool

TF-4 The Emergency Medicine Curriculum Assessment Tool

TF-5 Off-Service Resident ToolBox: A “Moment of Need” Emergency Medicine Curriculum for the Off-Service Rotator

Bedside and experiential learning are essential parts of emergency medicine education. Off-service residents (hereafter referred to as rotators) pose a particularly challenging group with which to engage in on-shift teaching due to their widely varying levels of prior knowledge and clinical experience. The Five Moments of Need Model described by Mosher and Gottfredson was designed for the corporate sector but offers significant parallels to the on-shift learning environment. E-Learning modalities lend themselves well meeting the resident in many “Moments of Need” and offer the rotator an opportunity to maximize their experiential learning during patient care. Prior efforts to develop a standard rotator curriculum predate the American College of Graduate Medical Education Milestones Project and have not been widely adopted. This curriculum uses an E-Learning repository as the core of a rotator curriculum. It augments a multi-modal approach addressing specialty-specific milestones for rotators. Study Objectives: To develop a rotator curriculum offering learning opportunities appropriate to several “moments of need.” After completion of this curriculum, rotators will: 1) Recognize patients with an unstable medical condition requiring acute stabilization, 2) Perform a focused history and physical exam appropriate to a patient’s chief complaint 3) Develop a differential diagnosis and treatment plan emphasizing acute life-threatening conditions. 4) Safely perform select emergency procedures under supervision. Rotators will be provided access to the Off-Service Resident ToolBox 2 weeks prior to the beginning of their rotation. The ToolBox is an online repository of brief written, video and PowerPoint-based modules. ToolBox content includes a practical introduction to the ED, a series of chief-complaint-focused clinical assessment modules, procedure videos, journal club materials, suggested reading and self-study quizzes. Rotators will be encouraged to review the materials prior to their rotation addressing the “Learning for the first time” and “Learning more” moments of need as well as on shift as preparation for patient evaluation addressing the “Applying what you’ve learned” and “When things change” moments of need. Rotators will apply knowledge gained through ToolBox materials and on-shift experience to their critical analysis of a variety of high-yield journal articles in a rotator-specific journal club led by emergency medicine faculty. Rotators will have 2 primary means of evaluation. Content-specific self-study modules are provided in the ToolBox to provide means of self-assessment. Rotators are evaluated by emergency medicine faculty through means of direct observation. Evaluations are milestone-based and completed via electronic survey response. Curriculum evaluation will be based upon before and after surveys assessing rotator confidence in clinical scenario management, content utilization, and satisfaction. Curricula designed for the rotating resident in the Milestones era are not widely available. The ToolBox offers an e-learning based rotator curriculum emphasizing provision of user-friendly modules at high-yield “moments of need” to maximize both clinical performance and experiential learning through direct patient care.

Intrinsic CanMEDS Competencies Expected of Medical Students During Emergency Medicine Core Rotation: A Needs Assessment.

ObjectivesThere are few high-quality free open-access medical (FOAM) education resources to guide medical students in the development of key non-medical expert skills and competencies during their emergency medicine (EM) clerkship core rotation. In our endeavor to develop a novel online educational EM curriculum for medical students, a needs assessment is required to effectively address needs specifically focused on aptitudes that are deemed to be imperative by educators in the EM academia.MethodsAn online needs assessment survey was developed and shared with residents, staff, nurses, and program/clerkship directors of Canadian emergency medicine programs by email correspondence and embedding the form on CanadiEM.org. The survey consisted of twelve proposed topics for a potential EM curriculum, which were graded on a five-point Likert scale. Free-typed responses for additional topics were also solicited from participants.ResultsOver the course of four weeks, 84 participants responded to the survey. Participants outside of North American were excluded (n=10). Most participants were North American staff physicians (n=52), which included residency program directors (n=10) and clerkship directors (n=6), followed by residents (n=14), and nurses (n=8). All 12 topics proposed by the authors were considered important for inclusion in an EM curriculum. Nine additional topics were identified from typed free-text responses. Top ranking topics included: how to present a case to an EM staff or resident, how to chart patient encounters, and how to effectively communicate with nurses and other healthcare professionals.ConclusionsThis online needs assessment analysis revealed a total of 21 topics that were deemed to be relevant to the development of an online curriculum to foster the development of core competencies of medical students during their EM core rotation.

Clinical Informatics Competencies in the Emergency Medicine Specialist Training Standards of Five International Jurisdictions.

The field of clinical informatics (CI), and specifically the electronic health record, has been identified as a key facilitator to achieve a sustainable evidence-based health care system for the future.International graduate medical education (GME) programs have been challenged to ensure that their trainees are provided with appropriate skills to deliver effective and efficient health care in an evolving environment. This study explored how international emergency medicine (EM) specialist training standards address competencies and training in relevant areas of CI. A list of categories of CI competencies relative to EM was developed following a thematic review of published references documenting CI curriculum and competencies. Publicly available documents outlining core content, curriculum, and competencies from international organizations responsible for specialty GME and/or credentialing in EM for Australasia, Canada, Europe, the United Kingdom, and the United States were identified. These EM training standards were reviewed to identify inclusion of topics related to the relevant categories of CI competencies. A total of 23 EM curriculum documents were included in the review. Curricula content related to critical appraisal/evidence-based medicine, leadership, quality improvement, and privacy/security were included in all EM curricula. The CI topics related to fundamental computer skills, computerized provider order entry, and patient-centered informatics were only included in the EM curricula documents for the United States and were absent for the other jurisdictions. There is variation in the CI-related content of the international EM specialty training standards reviewed. Given the increasing importance of CI in the future delivery of health care, organizations responsible for training and credentialing specialist emergency physicians must ensure that their training standards incorporate relevant CI content, thus ensuring that their trainees gain competence in essential aspects of CI.

Introduction of a Novel Evidence-Based Medicine Curriculum in Emergency Medicine

Evidence-based medicine (EBM) has become the quintessential goal of clinical decision-making. The study objective is to determine if a novel interactive EBM curriculum will improve resident physician EBM comprehension, assessed via a common EBM evaluation instrument, the Berlin Questionnaire (BQ). The BQ was administered to all residents at the start of the academic year and again following completion of the 12-month study period and EBM curriculum. The curriculum was designed based on readings from the JAMA Users’ Guides to the Medical Literature coupled with real-world, specialty-specific articles that reflect the major topic of each chapter of the text and was utilized to supplement the Emergency Medicine (EM) residency’s monthly “journal club.” Descriptive statistics, examination of self-evaluation, and analysis of test results were evaluated. Fifty-four EM residents completed the course. Wilcoxon signed-rank testing revealed a significant difference between pre- and post-intervention scores: [Z = − 3.114, p = 0.002], [Z = −3.327, p = 0.001] for post-graduate year (PGY)1 and PGY2, respectively. PGY3 had a borderline significant difference pre to post with [Z = − 1.693, p = 0.05], and PGY4 had a non-significant difference with [Z = − 1.769, 0.77]. Kruskal-Wallis H testing confirmed a significant difference between PGY pre-intervention scores with χ2(3) = 13.957, p = 0.003. A pairwise comparison of PGYs demonstrated a significant difference between the pre-intervention scores of PGY4s compared to PGY1s (p = 0.006) and PGY2s (p = 0.015). There was no significant difference between other PGYs. Kruskal-Wallis H testing comparing post-intervention scores demonstrated no significant difference between PGYs with χ2(3) = 0.575, p = 0.902. The post-intervention difference in PGY1, PGY2, and PGY3 BQ scores suggests improved knowledge after new EBM curriculum. Significant difference between pre-intervention scores of PGY1 or PGY2 when compared to PGY4 suggests that capacity to learn EBM is dependent on the training year. A clustering of high scores among all years post-intervention suggests that the EBM course improved PGY1 and PGY2 to PGY4 level over the course of 12 months.

P071: Content of clinical informatics in international training standards for emergency medicine specialists

Introduction: The field of Clinical Informatics (CI) and specifically the electronic health record, has been identified as a key facilitator to achieve a sustainable evidence-based healthcare system for the future. International graduate medical education programs have been challenged to ensure their trainees are provided with appropriate skills to deliver effective and efficient healthcare in an evolving environment. This study explored how international Emergency Medicine (EM) specialist training standards address training in relevant areas of CI. Methods: A list of categories of CI competencies relative to EM was developed following a thematic review of published references documenting CI curriculum and competencies. Publically available, published documents outlining core content, curriculum and competencies from international organizations responsible for specialty graduate medical education and/or credentialing in EM for the United States, Canada, Australasia, the United Kingdom and Europe. These EM training standards were reviewed to identify inclusion of topics related to the relevant categories of CI competencies. Results: A total of 23 EM curriculum documents were included in the thematic analysis. Curricula content related to critical appraisal/evidence based medicine, leadership, quality improvement and privacy/security were included in all EM curricula. The CI topics related to fundamental computer skills, computerized provider order entry and patient-centered informatics were only included in the EM curricula documents for the United States and were absent for each other organization. Conclusion: There is variation in the CI related content of the international EM specialty training standards which were reviewed. Given the increasing importance of CI in the future delivery of healthcare, organizations responsible for training and credentialing specialist emergency physicians must ensure their training standards incorporate relevant CI content, thus ensuring their trainees gain competence in essential aspects of CI.

Do senior medical students meet recommended emergency medicine curricula requirements?

BackgroundEmergency departments (EDs) offer a variety of learning opportunities for undergraduate medical students. It is however, difficult to evaluate whether they are receiving recommended training during their emergency medicine (EM) clerkship without identifying their clinical activities. We aimed to evaluate the clinical exposure of the final year medical students at our College during their EM clerkship.MethodsThis is a retrospective analysis of prospectively collected student logbooks. 75 students rotated in a 4-week EM clerkship during 2015–2016. The students rotated in EDs of two hospitals. Each ED treats more than 120,000 cases annually. The students completed 12 eight-hours shifts. Presentations and procedures seen were compared with EM curriculum recommendations.ResultsFive thousand one hundred twenty-two patient presentations and 3246 procedures were recorded in the logbooks, an average (SD) of 68.3 (17.6) patients and 46.1 (14.0) procedures. None of the students encountered all ten recommended presentations. Two students (2.6%) logged all nine procedure categories of the EM curriculum.ConclusionRecommended presentations and procedures of the EM clerkship were not fully encountered by all our students. Different settings vary in the availability and type of patients and procedures. Each clinical clerkship should tailor their teaching methods based on the available learning opportunities.