Introduction
Disaster medicine (DM) represents a unique field of emergency medicine (EM) that has recently experienced significant professional development. Over the last several decades, war-related humanitarian crises, climate change disasters, and emerging infectious diseases, among other events, have required increasingly complex responses. An effective strategy must incorporate national and international assistance networks, be sensitive to local religious and political views, and consider the local availability of resources, or lack thereof. The shortcomings in these domains became acutely apparent following the 2010 earthquake and floods in Haiti and Pakistan, with leading organizations calling for improved “coordination, accountability, transparency, stringent oversight and control, and professionalism,” both during and after crisis events. 1,Reference Burkle2
Currently, DM is not recognized by the American Board of Medical Specialties (ABMS; Chicago, Illinois USA), the most prominent organization that sets professional standards and provides board certification for member subspecialties and physicians. As of 2023, there are eleven ABMS-approved EM subspecialties – Anesthesiology Critical Care Medicine; Emergency Medical Services (EMS); Health Care Administration, Leadership, and Management; Hospice and Palliative Medicine; Internal Medicine-Critical Care Medicine; Medical Toxicology; Neurocritical Care; Pain Medicine; Pediatric EM; Sports Medicine; and Undersea and Hyperbaric Medicine. 3 Additionally, the ABMS recognizes Advanced EM Ultrasonography as a Focused Practice Designation (FPD), which represents physicians who spend a large portion of their practice in a specific area of a subspecialty. 4
For a subspecialty to be recognized by the ABMS, it must represent a unique body of knowledge not adequately addressed in other curricula, contain a significant number of physicians practicing in the field, and have a proportionate amount of fellowship programs. Reference Brice, Perina, Liu, Braude, Rinnert and MacDonald5 Additionally, in order for an individual physician to qualify for ABMS board certification, they must have completed graduate medical training at a program accredited by the Accreditation Council of Graduate Medical Education (ACGME; Chicago, Illinois USA), which is the governing body that sets educational standards for graduate medical education (GME). 6–8 However, DM fellowships are not currently accredited by the ACGME, and therefore, no standardized DM curriculum exists.
In the absence of a formal curriculum, the Society of Academic Emergency Medicine (SAEM; Des Plaines, Illinois USA) has previously developed a DM curriculum that they may recommend fellowship programs to adopt, allowing the program to be classified as “SAEM approved.” 9,10 However, a recent study analyzed EM residency and EMS fellowship curricula for inclusion of SAEM-recommended DM topics and highlighted a significant gap in the unique DM body of knowledge covered, showing that only 40% of the DM curriculum subtopics will be covered in the course of an EM residency followed by EMS fellowship. Reference Sandifer, Wexler and Flamm11
A new article by Wexler, et al provides the first standardized curriculum to be used as a foundational course of study for DM fellowship programs in the United States. This curriculum was developed by members of the Council of Disaster Medicine Fellowship Directors and seeks to contribute to the development of DM board certification by defining relevant content and topics for future examinations. Reference Wexler, Schultz and Biddinger12 This present study will analyze the components of this curriculum for topics that are currently addressed by EM residency and EMS fellowships in the United States. The hypothesis is that there is a large body of DM knowledge outlined in this curriculum that is not being addressed by either EM residency or EMS fellowship.
Methods
Control Curriculum
The DM curriculum topics and subtopics were derived from The 2023 Model Core Content of Disaster Medicine. Reference Wexler, Schultz and Biddinger12 This curriculum was chosen as it represents the most current content recommendations for DM fellowships and was developed by members of the Council of Disaster Medicine Fellowship Directors. This curriculum is organized by fifteen major topics with related subtopics, which can be viewed in Figure 1, and has been cross-referenced with the ACGME and ABMS Core Competencies.
Disaster Medicine (DM) Fellowship Core Curriculum.
EM and EMS Training Curricula
The EM residency curriculum was obtained from The 2019 Model of the Clinical Practice of Emergency Medicine. This curriculum was chosen because it has been approved and is continuously reviewed by leading EM organizations, including the American Board of Emergency Medicine (ABEM; Lansing, Michigan USA), the Council of Emergency Medicine Residency Directors (CORD; Irving, Texas USA), American College of Emergency Physicians (ACEP; Irving, Texas USA), the Emergency Medicine Resident’s Association (EMRA; Irving, Texas USA), the Residency Review Committee for Emergency Medicine (RRC-EM; Chicago, Illinois USA), SAEM, and the American Academy of Emergency Medicine (AAEM; Milwaukee, Wisconsin USA). This curriculum has been cross-referenced with the ACGME six core competencies for the practice of medicine. Reference Beeson, Ankel and Bhat13
The EMS fellowship curriculum was obtained from The 2019 Core Content of Emergency Medical Services Medicine. This curriculum was chosen because it was developed and is continuously reviewed by leaders in EM and EMS, including the National Association of EMS Physicians (NAEMSP; Washington, DC USA) and ABEM. This curriculum has also been cross-referenced with the ACGME six core competencies for the practice of medicine. Reference Delbridge, Dyer and Goodloe14
Study Design
The EM residency and EMS fellowship curricula were reviewed for inclusion of the DM major curriculum topics and subtopics, using the DM curriculum recommendations published by Wexler, et al as a control. Reference Wexler, Schultz and Biddinger12 The initial curriculum review for included topics was performed by one author with subsequent review by all authors. A DM major curriculum topic was considered to be covered by EM residency or EMS fellowship if at least one of the related subtopics were described in the curriculum. Furthermore, a DM major curriculum topic or subtopic was only considered as being included in the EM residency or EMS fellowship curriculum if the wording was an identical match to the control DM fellowship curriculum. Included and excluded DM topics and subtopics were analyzed using descriptive statistics.
Results
The control DM curriculum was organized into major curriculum topics with related subtopics, which can be viewed in Figure 1. While all the DM major curriculum topics were covered by either EM residency or EMS fellowship, EMS fellowship covered more major curriculum topics (14/15; 93%) than EM residency (12/15; 80%). A comparison of the DM major curriculum topics included in EM residency and EMS fellowship may be viewed in Table 1.
DM Major Curriculum Topics Covered by GME Programs
Abbreviations: DM, disaster medicine; EMS, Emergency Medical Services; EM, emergency medicine; CBRNE, chemical, biological, radiation, nuclear, and explosives; GME, graduate medical education.
Alone, EMS fellowship covered more DM curriculum subtopics (58/153; 38%) than EM residency (24/153; 16%). Combined, EM residency and EMS fellowship covered 65/153 (42%) of the DM curriculum subtopics. A comparison of the inclusion of DM curriculum subtopics by GME programs can be viewed in Table 2.
DM Curriculum Subtopics Covered by GME Programs
Abbreviations: DM, disaster medicine; EMS, Emergency Medical Services; EM, emergency medicine; CBRNE, chemical, biological, radiation, nuclear, and explosives; GME, graduate medical education.
Of note, the DM major curriculum topic chemical, biological, radiological, nuclear, and explosives (CBRNE) represented the largest topic covered in EM residency and EMS fellowship, with 14/46 (30%) and 22/46 (48%) of subtopics being represented in the curriculum, respectively. A sub-group analysis of the DM curriculum subtopics was performed excluding the CBRNE major curriculum topics and may be viewed in Table 3. In this analysis, EMS fellowship covered 36/153 (24%) of subtopics, while EM residency covered 10/153 (7%) of subtopics. Combined, EM residency and EMS fellowship covered 39/153 (25%) of CBRNE subtopics.
Subgroup Analysis of DM Curriculum Subtopics, Excluding CBRNE
Abbreviations: DM, disaster medicine; EMS, Emergency Medical Services; EM, emergency medicine; CBRNE, chemical, biological, radiation, nuclear, and explosives.
Discussion
This study contributes to the previously reported findings that there is a substantial body of DM knowledge that is not being covered in EM residency or EMS fellowship curricula. Using the most current and inclusive DM curriculum as a control, this study found that although a physician training in EM residency followed by EMS fellowship will have touched upon each of the DM major curriculum topics, they will covered less than one-half (65/153; 42%) of the curriculum subtopics (Table 1 and Table 2).
In the analysis, a DM major curriculum topic was deemed covered if at least one of the related subtopics was described in the program’s standardized curriculum. However, a large portion of fundamental DM major curriculum topics, such as Medical Oversight of Emergency Management Systems, contained subtopics that were only marginally covered by either EM residency (1/17; 6%) or EMS fellowship (6/17; 35%), as shown in Table 2. Additionally, the DM major curriculum topic Mass Care and Environmental Disasters, which includes increasingly relevant subtopics such as climate change, drought, and flooding, as seen in Figure 1, is technically covered by both EM residency and EMS fellowship curricula. However, further analysis shows both EM and EMS training curricula only cover the single subtopic heat emergencies.
Furthermore, the focus of a DM topic covered in EM residency or EMS fellowship may be dependent upon the educational goals of the program. Although EM residency and EMS fellowship both cover a large portion of the CBRNE subtopics, the way these topics are covered likely differs greatly than that of a DM fellowship. While EMS will primarily focus on initial triage and prehospital management in individual exposed civilians and responders, a DM curriculum will place an additional emphasis on mass treatment, emergency preparedness, and resource management on a mass scale. Coverage of DM topics may also be limited by the length of these existing training programs. The EMS fellowship, which constitutes a yearlong fellowship with its own unique base of knowledge, is unlikely to have sufficient time and resources to cover additional DM topics in sufficient depth to produce optimally trained DM physicians.
As the field of DM continues to evolve, it is instructive to consider the pathway to ABMS and ACGME recognition for other subspecialities of EM. In the mid-1990s, the field of EMS developed a task force to petition for board certification by the ABMS, led by Dr. Jon Krohmer. They concluded that “physicians who provide medical direction for EMS systems should meet standardized minimum requirements for training and certification,” ultimately becoming officially recognized as a subspecialty by the ABMS in 2010. Reference Brice, Perina, Liu, Braude, Rinnert and MacDonald15,16 This certification paved the way for the standardization of an EMS curriculum by the ACGME, as graduation from an ACGME-accredited GME program is required for a physician to be board certified by the ABMS. This helped to facilitate the maturation of EMS fellowships as well as the specialty itself. Reference Brice, Perina, Liu, Braude, Rinnert and MacDonald5,7,Reference Clemency, Martin-Gill, Rall, Patel and Myers17
It is increasingly important that a formalized training and certification structure exists within DM to ensure uniform clinical competence amongst responding physicians as disaster response becomes more complex. An ABMS board certification process would stimulate the development of DM by establishing and upholding professional standards, thus fostering trust amongst the public and other responders. Accreditation by the ACGME would allow for the development of a standardized curriculum to promote the development of disaster-ready physicians, as well as an educational pathway for physicians to become ABMS board certified in DM.
Limitations
A limitation of this study is the binary nature of how a DM major curriculum topic was considered to be covered by EM residency or EMS fellowship. A major curriculum topic was considered to be covered if at least one of the related subtopics was described in the EM residency or EMS fellowship curriculum. However, the extent and focus with which these subtopics are taught was not assessed and may have resulted in the over-reporting of the amount of DM major curriculum topics covered in current GME programs.
Additionally, a DM major curriculum topic or subtopic was only considered as being included in the EM residency or EMS fellowship curriculum if the wording was an identical match to the control DM fellowship curriculum. However, a DM curriculum topic or subtopic that appears to be excluded from either GME curricula may instead be covered in a separate curriculum heading. For example, although the subtopic “Medical Surge Capacity” (4.8) is not specifically listed in the EMS curriculum, it may be included in the subtopic “Hospital Preparedness” (5.3); Figure 1. This may have resulted in the under-reporting of major topics and subtopics included in the EM residency and EMS fellowship programs. Further analysis of the specific educational objectives of each curriculum topic and subtopic in GME programs will be required for complete assessment of included DM components. This study analyzed residency and fellowship programs available in the United States only, and as such, findings presented are not externally valid for programs located outside of the United States.
Conclusion
This study sought to update the coverage of DM curriculum topics and subtopics, using the most current and inclusive suggested DM curriculum available, currently being addressed in EM residency and EMS fellowship curricula in the United States. Although it finds that all the DM major curriculum topics will be covered in EM residency followed by EMS fellowship, over one-half of the subtopics are not covered by the either program (16% and 38%, respectively) or both programs combined (42%). Increasingly relevant subtopics, such as climate change, droughts, and flooding, are amongst those not covered by either curriculum.
Even among DM topics and subtopics included in GME curricula, there is no educational standard for the way in which these topics are addressed. This may result in inconsistencies in DM knowledge and skills, even amongst the most disaster-prepared EM and EMS physicians.
Conflicts of interest/funding
The authors Sara P. Sandifer, Bryan J. Wexler, and Avram Flamm declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
