Abstract
Introduction
Wilderness medicine education is one of the fastest growing facets of both graduate and undergraduate medical education. Currently, there are curriculum guidelines for both student electives and fellowships in wilderness medicine. However, there are no guidelines for resident elective curricula. The student/resident education committee of the Wilderness Medical Society (WMS) convened a task force to develop curriculum guidelines for these electives.
Methods
A survey of previously described core wilderness medicine topics was sent to a cohort of educators involved in wilderness medicine resident electives. They were asked to rank topics on the basis of their importance of being included on a Likert scale. Multivariate analysis of medians was used to distinguish among topics to determine which topics were voted most and least necessary for a curriculum.
Results
Of the database members contacted, 35 responded to the survey. The described current state of residency electives was that 16 institutions offered their own elective (46%). For subject preferences, multivariate analysis of scoring distribution medians demonstrated a significantly higher pattern of responses (P<0.01) for subjects with a median of 3 (must include) than for the lowest-scoring subjects that had a median of 1 (can include). Every topic was rated “must” by at least 1 respondent. Topics were further subdivided into an educational framework reflecting a common approach to education of wilderness medicine fellows focusing on education, leadership, knowledge, and skills.
Conclusions
There was a wide variety in the ranking of topics; however, there were multiple topics on which a consensus for inclusion was reached. These topics are organized and presented here as a suggested curriculum by the student/resident education committee of the WMS.
Introduction
Both the interest in and popularity of wilderness medicine educational programs have been growing in undergraduate and graduate medical education. These curricula emphasize important skills and techniques that span multiple medical specialties. A 2015 study showed that 75% of emergency medicine residencies offer wilderness medicine educational content and 44% of surveyed programs require residency-level education and exposure to the topic. 1 Although some physicians may not frequently encounter specialty-specific conditions in their practice, such as altitude medicine, envenomation, or extreme environmental conditions, all trainees can benefit from the overarching tenets of wilderness medicine, including the ability to provide emergent interventions and stabilization, improvisation and adaptability, and teamwork and peer leadership. The specialty’s catalog of unique pathophysiology draws from multiple medical and surgical subspecialties, and its core concepts highlight uniquely necessary but less common experiences for developing physicians. These include scarcity of resources, need for improvisation, and independence of clinical examination and judgment. 1
Discussion and recommendations for the development of wilderness medicine fellowships, longitudinal residency specialty tracks, and medical student–level electives have been previously described. 2 -4 However, there are no established recommendations on the development of content, topics, or best practices for residency-level wilderness medicine electives (traditionally a 2–4-wk rotation over the course of a trainee’s resident program, but there is significant variation in course organization to include students, inside-the-organization rotators, outside-the-organization rotators, or any combination thereof). Lacking consensus, these experiences can potentially vary greatly and may emphasize a wide range of subtopics within the specialty. 5 Understanding the current design and organization of these electives is imperative to provide guidance for continued growth and evolution in previously established wilderness medicine electives and to provide tools and recommendations for new programs interested in developing their own curriculum.
The resident/student education committee of the Wilderness Medical Society (WMS) convened a task force to research current practices in resident education with the aim to summarize curricula for resident rotations in wilderness medicine. The goal was to explore wilderness medicine subjects that are currently being emphasized in active programs and to identify what topics may be under-represented, requiring further implementation. These objectives were achieved by examining survey results about the characteristics of their wilderness electives from current residency elective directors and program participants affiliated with the WMS or American College of Emergency Physicians (ACEP) wilderness medicine subsection. The questions and topics queried in this survey were derived from a previous study regarding topics for student elective development attempting to identify similar outcomes. 2
Methods
Using the topics historically included within the current WMS resident curricula and existing medical student curriculum guidelines, a previously described list of all potential topics within a resident elective curriculum was consolidated into a survey.2,6 Each topic was also evaluated to ensure relevance to the 6 Accreditation Council for Graduate Medical Education (ACGME) core competencies. 7 The survey was undertaken in an effort to inform the committee’s work in drafting recommendations for this education space.
The survey was sent to members of the WMS student/resident committee through the Basecamp application, reaching 36 members. The survey was also sent to the ACEP listserv (
We asked survey participants to identify the institution they represented if that institution offers its own resident wilderness medicine program and if it was open to “outside” residents, meaning those not currently training at that hospital. We then collected data regarding the respondent’s current specialty, level of training, and expertise.
We asked the surveyed participants to rank each topic on a Likert scale as 0, should not; 1, can; 2, should; or 3, must (include). These qualifiers were selected to be in line with the standards set forth by the Liaison Committee on Medical Education (LCME) and have been used previously in wilderness literature. 2 Both the terms “should” and “must” have specific uses in LCME literature. Use of the term “must” in the document indicates the standard to be absolutely necessary for the achievement and maintenance of accreditation. Use of the word “should” indicates that compliance with the standard is expected in the absence of extraordinary and justifiable circumstances that preclude full compliance. 8 The terms “can” and “should not” were selected to match the established language and assist with data collection. We hypothesized that significant preferences for and against certain subjects could be identified by analyzing the median responses for each subject. Data were compiled in a Microsoft Excel (Redmond, WA) spreadsheet, and the mean and SD were calculated for each topic. To identify which topics were most voted as necessary (majority “3” responses) and least voted as necessary (majority “1” responses), medians were compared due to the ordinal but noncontinuous nature of the data. To identify any significant differences between medians, ranked medians were compared using multivariate analysis in Stata version 12.1 (College Station, TX) by Kruskal-Wallis testing, with post hoc testing by the Dunn method using Bonferroni correction for multiple comparisons. Potential topics with a median score of 3 were summarized by this committee as “must include,” and topics with a median score of 2 were listed as “should include.”
Results
Of the database members contacted, 35 responded to the survey. Seventeen were current or former wilderness medicine resident elective directors. Eight were residents who had participated in wilderness medicine training, 24 practiced emergency medicine, 6 practiced family medicine, 3 practiced internal medicine, 1 practiced oral maxillofacial surgery, and 1 was a registered nurse. Thirty-one were WMS members, and 17 were ACEP wilderness medicine section members.
Twenty-one respondents represented institutions offering their own resident wilderness medicine course. Sixty-six percent of respondents noted that their elective allows outside (rotating) residents. Sixteen institutions offered their own elective (46%), 14 did not (40%), 1 offered a wilderness track, 1 had a combined resident/student elective, 1 had a wilderness weekend, and 2 offered advanced wilderness life support training.
Table 1 demonstrates all the survey topics that respondents were asked to rank as well as the tally of scores, median, mean, and SD for each topic. Multivariate analysis of scoring distribution medians demonstrated a significantly higher pattern of responses (P<0.01) for subjects with a median of 3 (must include) than for the lowest-scoring subjects that had a median of 1 (can include). Every topic was rated “must” by at least 1 respondent. However, the topics wildland fires, high-angle rescue, pediatrics in wilderness, legal issues in wilderness medicine, and interpersonal and communication skills were also rated as “should not” be taught by at least 1 respondent. Topics recommended as “not covered in the above” by the free text option included wilderness medicine education, event medicine, veterinary medicine, tactical medicine, and global medicine. Table 2 reflects topics that the survey respondents recommended must be included (median score of 3) and should be included (median score of 2). Topics were placed into an educational framework reflecting a common approach to education of wilderness medicine fellows focusing on education, leadership, knowledge, and skills. 3 Skills were further broken apart into wilderness survival and patient care skills because the objectives of these topics are often different. Education was not included in this framework because resident electives do not focus on training educators to the same extent that fellowships do. As such, our framework included wilderness survival for the practitioner, leadership skills, practical field management, and common wilderness pathology.
All topics that the respondents were asked to rate using a Likert scale of 0, should not; 1, can; 2, should; and 3, must (include) and the tally of scores, median, mean, and SD of the scores
Ob/Gyn, obstetrics and gynecology; EMS, emergency medical services.
The topics are ranked in order of mean scores.
Topics that “must” and “should” be included: topics were divided into the educational framework of wilderness survival for the practitioner, leadership skills, practical field management, and common wilderness pathology
EMS, emergency medical services; Ob/Gyn, obstetrics and gynecology.
Discussion
Among those surveyed, there was a varied response as to what should be included in a resident wilderness curriculum. However, there was some general agreement that certain core subjects “must” be included and many subjects “should” be included (Table 1). These are presented as organized into the following educational framework categories: wilderness survival for the practitioner, leadership skills, practical field management, and common wilderness pathology (Table 2).
It is clear from the survey results that there is significant disparity among residency programs as to whether a wilderness elective is offered (46% vs 40%), whereas 14% offered some form of formal training in wilderness medicine that they did not describe as a traditional elective. Efforts toward highlighting what can be considered a “core curriculum” may facilitate an increase in elective availability nationwide. To that end, the survey demonstrated a clear pattern of preference in respondents’ curricula for conditions that are encountered only in the wilderness: be it for pathophysiologic reasons specific to the environment (eg, heat/cold, altitude, envenomation, zoonosis) or for conditions that are uniquely complicated by austere settings (eg, trauma, evacuation, blister management). Although wilderness-specific conditions were preferred by respondents in general, highly technical fields, such as wildland fires and high-angle rescue, were not only significantly less recommended but also rated by some as “should not be taught.” We would posit that this pattern of lack of preference potentially even carries over to the nuanced technical fields of cave, avalanche, and whitewater rescue, and hyperbaric medicine. This may be because technical fields may require outside expertise not present in local faculty members, which may be an alternative reason why they were not recommended, but the cause of this lack of preference was not specifically investigated in the current study.
In addition to the core wilderness topics, respondents maintained a strong preference for the system-based learning and interpersonal and communication skills that are highlighted by practicing in a more austere environment. These competencies are generalizable to multiple medical specialties. Core wilderness medicine topics are included in an entire section of the American Board of Emergency Medicine’s Model of the Clinical Practice of Emergency Medicine 2019 model and are relevant to the ACGME’s core competencies for all residencies. 9 Multiple topics from the proposed wilderness medicine curriculum address each of the competencies, making these electives very well rounded (Table 3). Specifically, wilderness medicine electives have a strong focus on resource-limited care and interpersonal abilities, such as leadership of a multiple disciplinary team, that may not be encountered in other residency electives. The teaching of these types of skills is demonstrated by content inclusion in areas such as environmental ethics, incorporating wilderness medicine with emergency medical services, issues of medical futility, legal issues in wilderness medicine, risk management and judgment, and leadership and teamwork in the wilderness.
Relevance of topics to Accreditation Council for Graduate Medical Education residency core competencies
Ob/Gyn, obstetrics and gynecology; EMS, emergency medical services.
All 6 of the core competencies were addressed by multiple subjects within the curriculum.
Considering the breadth of topics within wilderness medicine, the question remains as to whether it is best covered by previously described curriculum tracks 4 or as is described as more common among our respondents, an isolated 4-wk elective. Although 4 wk may not be adequate time to completely address all these topics, it does provide residents with an introductory dive into the topic to further their education and explore potential career opportunities. Residents looking to delve deeper would thus be encouraged to pursue a wilderness medicine track or fellowship. This committee currently maintains support for both track-based and elective-based rotation models.
Limitations
Limitations of the study include its underpenetration among all residency programs due to being a peer survey methodology. Although the study was sent to 36 members of the WMS student resident committee, it was also sent to the ACEP wilderness medicine section listserv with an unknown number of members; hence, a response rate could not be determined. The selection of the ACEP listserv does introduce bias toward emergency medicine and the US population. However, this broad survey does provide the most recent generalized data on the field of resident education in wilderness medicine pertinent to our committee’s focus. Additional limitations include the lack of questions on how the various educational objectives are achieved (simulation, moulage, testing, student subject preference, etc.) and the varying responses within the survey that likely reflect differing levels of local expertise and environments and, in consideration of which, we have maintained our recommendations as summary suggestions. Overall, this committee’s focus was to provide initial recommendations for general curriculum topics to be considered essential for inclusion in resident wilderness medicine curricula. In doing so, our initial findings inherently lack specificity and warrant further research to identify essential material within each topic and to examine ideal educational methodologies (eg, simulation, didactics).
Conclusions
In developing, ranking, and organizing consensus for which historical student topics were deemed most important to a limited group of wilderness medicine resident educators, this committee’s recommendations are presented for reference by new or growing programs. Recognizing the broad range of subjects to cover in the field, we continue to encourage topic emphasis according to local needs/resources and encourage ongoing study of the educational space.
Footnotes
Acknowledgments
This author group acknowledges the noteworthy contribution of their colleagues in the Wilderness Medical Society education committee sub–task force—Lauren Altschuh, Jeff Conley, Alex Dinello, Kara Hatlevoll, Danny Leiva, Lara Phillips, and CJ Waasdorp—for their indispensable assistance.
Author Contributions: study concept and design (AM, SAL); data acquisition (AM, SAL); data analysis (MDW); drafting and critical revision of the manuscript (AM, GBC, MDW, WBP, JMG, SAL); all authors approved the final manuscript.
Financial/Material Support: None.
Disclosures: None.