Discussion
Not only in the general public but also in medical professional life, there is the perception that every physician has to be able to handle critical emergency situations regardless of the location, severity of the emergency or the individual's prior experience [
6]. Consequently, in 1998, the Society of American Emergency Medicine Physicians (SAEM) described three core subjects to be taught within medical school curricula: BLS skills, including the diagnosis and treatment of shock; treatment of common acute problems; and assessment of undifferentiated patients [
2]. Undoubtedly, there is a need for compulsory implementation of emergency medical care content in undergraduate medical education, and in particular, many studies have revealed a low standard of necessary CPR skills in medical students and recently graduated physicians [
7‐
9]. Jagoda et al. cited the Macy Foundation report on emergency medicine when stating "...medical school deans and faculties must ensure that every medical student has acquired the appropriate knowledge and skills to care for emergency patients" [
10,
11]. Accordingly, key issues in emergency medical care had to be implemented in undergraduate medical education both to fulfil the expectations of the public and society, and to invent these special core objectives as early as possible [
2].
Nevertheless, few data or concepts have been described in the literature within the last ten years. In 2001, Philips and Nolan presented data from a questionnaire at UK medical schools, where compulsory BLS training was achieved for 100% of students and some sort of compulsory ALS training was implemented at most schools [
6]. Finally it was unanswered, what kind of training is able to produce the necessary skills concerning ALS postulated by the Royal College of Physicians [
12]. A comparable questionnaire from 2002 found that most US medical schools provide training in emergency medical care within their first two academic years, lasting from hours to weeks, and resuscitation training was scheduled in approximately 16% of the schools [
13]. In addition, skills in cardiopulmonary resuscitation at the levels of BLS or ALS should be implemented in undergraduate medical education as early as possible. The 2003 publication "ILCOR Advisory Statement" summarizes this topic with a specific recommendation that "all healthcare providers should be able to demonstrate competency in the skills of BLS" and formulates that "Healthcare professionals must receive their initial training in BLS while students" [
14,
15].
Since new regulations were established in Germany in 2002, different local concepts for emergency medical care in undergraduate education were published, which incorporated BLS or ALS training in differing amounts [
16‐
18]. However, no systematic and comparable nationwide survey exists to date. The present enquiry gives for the first time a nationwide overview of key elements of undergraduate education in emergency medical care and helps to update knowledge about curricula in order to describe international comparisons.
The interdisciplinary aspect of emergency medical care as a discipline is confirmed by the academic specialties involved, even though in particular cases substantial variation resulted from the local impact of special disciplines. At each site, different specialties are involved, along with a differing quantity – measured in semester periods per week – and quality with respect to the educational methods that are used. Putting these observations together, we can state that there is a sound foundation upon which the interdisciplinary development potential can be built, particularly with regard to teaching methods and their corresponding objectives. Against this background it is certainly arguable if in future emergency medicine as an own specialty of post-graduate training might be necessary or useful in order to harmonize curricular structure and content. In fact these issues are viewed very critically by existing specialties involved in emergency medical care such as anaesthesiology or traumatology.
In respect of course topics we found first of all that BLS and ALS is implemented at all faculties, but the time-frames are varying to a great extend (3 to 13 teaching units). In contrast to this diversity, as regards content the training of resuscitation in basic or advanced life support is very consistent: 94% follow the current ERC guidelines, and only two faculties are mostly AHA orientated. This is remarkable insofar as only five locations have an adequate pool of certified ERC-ALS-instructors available. Certainly this is a consequence of the fact that the German Resuscitation Council was founded as recently as 2007, and a structure for resuscitation training and qualification of instructors that is comparable to the Resuscitation Council UK or ERC does not exist to date. Undoubtedly international concepts have to be valuated and if necessary adapted and consequently implemented on a nationwide basis. However, many universities are offering high quality courses or activities with respect to methodical and didactic competencies for their own faculty, but without a widespread acceptance through all disciplines.
In spite of the uneven conditions and the lack of a sufficient number of certified instructors, most of the curricula utilize small group sessions for practical training, with four to eight participants and an instructor to student ratio of 1:3 to 1:6 depending on course content, as recommended in the 2005 ERC guidelines [
19]. This recommendation already follows the ILCOR Advisory statement concerning education in resuscitation, where Chamberlain et al. proposed "moving from large-group, lecture based courses to small-group, scenario-based interactive teaching" [
14,
15]. Again varying concepts are used to ensure small group sessions: at some sites, students with additional qualifications such as paramedic or EMT training are trained and appointed for peer-to-peer-teaching sessions [
20], whereas other locations try to make sure that only residents and consultants are integrated in practical training sessions [
17].
Despite evidence about the management of severe trauma in the pre-hospital [
21] or clinical setting, PHTLS-, ATLS-concepts or the program of the European Trauma Course (ETC) [
22] are rarely integrated into undergraduate medical education. In one way, this is certainly caused by the lack of nationwide course concepts for professionals that compare to PHTLS or ATLS. The latter, however, is getting more relevant through the initiative of the German Society of Traumatology, which holds the rights for the courses in Germany, but should be more integrated in undergraduate education core principles. For the TEAM concept (Trauma Evaluation and Management module), Ali demonstrated that participants were better trained in providing required trauma skills [
23,
24].
Problem-based learning (PBL) as a teaching method was invented and used for the first time by Barrows and Tamblyn in 1976 [
25]; since that time, this method found its way into newly designed as well as traditional curricula all over the world. At some medical schools, e.g. Maastricht, NL or Harvard, Boston, USA, it supports the underlying principle of the curriculum. PBL as a learning method is able to both generate knowledge to a certain extent, and to facilitate acquisition of competence with respect to problem solving strategies. Additionally, the students gained the foundation for individual life-long learning principles [
5,
25]. Within German medical schools, one PBL-based curriculum in emergency medical care has been published [
16], but even there, elements like practical training sessions and simulations are integrated. From the educational point of view, it is certainly in question whether the problem-based learning sessions should be used as a comparable method [
26]: Steadman et al. published data showing that simulation-based training was superior to PBL sessions in the acquisition of clinical skills in the field of critical care medicine [
27]. A recently published editorial by Diana Wood brings this discussion to another level [
28]: PBL should be accepted as one way of acquiring knowledge and problem-solving strategies as well as social skills.
Overall many contemporary and innovative teaching methods are integrated into German medical school curricula. In any case, the teaching sites have good technical features: at nearly every location, simulation technology is available to a certain extent. This is the result of a project with large-scale financial support initiated five years ago by the German Society for Anaesthesiology and Intensive Care Medicine (DGAI) to integrate simulation technology into local curricula. The main focus was to improve the quality of teaching, especially in emergency medical care, and so overall 32 Emergency Care Simulators (ECS; METI, Sarasota, FL, USA) were made available to medical schools all over the country. Besides the evidence that simulation-based training is a useful tool in medical education and is able to transfer important skills and knowledge [
29], different authors have approved the use of simulation technology within undergraduate curricula [
17]. Further potential operational areas like acute care in paediatric emergencies were previously presented by Eich et al. [
30]; crew resource management (CRM) was presented by Müller et al. [
31], resp. crisis resource management by Krüger et al. [
32]. Even if every site is technologically capable of providing simulation-based training, it is important to note that necessary operational expenses such as the costs for maintenance, manpower, consumables or repairs limit the widespread implementation of this curriculum [
33,
34]. Additionally, no qualification standard has been set for the instructor in simulation-based training, so that we can summarize in respect of this topic: In general the didactic as well as professional qualification for teaching at the sites is very inconsistent; a standardized concept including certification compared to the generic instructor concept of the ERC is needed to enhance nationwide quality in emergency medical care in future.
A well-known model to describe medical competence is Miller's pyramid, wherein four layers of competence are defined as "knows", "knows how", "shows how" and "does" [
35], and respective assessment methods are dedicated, e.g. on the level of "knows", written examinations are use with multiple-choice or open-answer questions. With respect to the assessment of CPR skills, the ILCOR-statement "education in resuscitation" postulated in 2003 "not to use written tests for CPR courses for laypersons but should be considered for healthcare professionals" [
14,
15]; Schuhwirth and van der Vleuten underline this statement by explaining that "one way to increase the authenticity of an assessment is to base it on a simulation of reality" [
36]. On the level "shows how", Harden et al. described the so-called "OSCE"-Objective Structured Clinical Examination. Since then, OSCE has been promoted to an accepted and applied tool for the assessment of practical performance in standardized settings with prepared checklists [
37,
38]. An additional effect is that, as teachers know, "assessment drives learning": OSCE provokes students' learning behaviour toward practical performance and problem-solving skills as well as the individual power of judgement [
39]. Despite these facts, OSCE as obligatory assessment method is utilized at one third of the schools, likely caused by the organisational and financial side effects of this "tool". Because multiple choice questions that only test the level of "knows" are used at nearly every site, the exchange of concepts and experiences necessary to bring OSCE into practice has to be facilitated. A promising concept with integration of essential emergency procedures such as BLS, ALS or diagnostic skills will be published shortly by Walcher et al.
Furthermore, the elective course offerings are often more innovative, but should be used as a preliminary stage for the widespread implementation of new concepts, and therefore communication between faculties is a necessary progression. In the future, it might be useful and interesting for applicants to see how specific locations set their priorities within the field of emergency medical care as a prime example of an interdisciplinary medical subject.
As a limitation, it is necessary to mention that we cannot rule out that in the meantime, at some locations, teaching methods such as e-learning or sessions with simulation technology or applied assessment methods have slightly changed.
However, future studies should analyse whether the different teaching and assessment methods lead to different capabilities and outcomes in the practice of emergency medical care.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
SB, AT, MM, MA and FW had the initial idea to the study and arranged the study design and questionnaire. Literature search was performed by SB and AT, collecting of the data was performed by SB, AT, MM, MA, and FW and analysis and interpretation of the data was done by SB, AT, MM, MA, and FW. SB, AT, MM, MA and FW wrote and reviewed the manuscript before submission. All authors read and approved the final manuscript.