Background
Stroke and transient ischemic attacks (TIA), among other neurological complaints, currently account for 5% of emergency department (ED) visits. 1 The treatment of these conditions is time-sensitive, requiring expert and expedited care to prevent morbidity and mortality.Reference Rothwell and Warlow 2 - Reference Harraf, Sharma and Brown 4 Over the last 15 years, diagnostic and therapeutic approaches in the management of acute ischemic stroke have evolved rapidly. Computed tomography (CT) or magnetic resonance imaging (MRI) now allows the skilled physician to quickly and accurately identify subtle signs of stroke and candidates for thrombolysis.Reference Schriger, Kalafut and Starkman 5 , 6 Thrombolytic therapies, administered early and appropriately, are known to improve patient morbidity and mortality.Reference Lees, Von Kummer and Bluhmki 7 Still, the complexity and variety of presentations of these conditions pose recognized challenges in diagnosis and management among emergency physicians and residents.Reference Pope and Edlow 8 - Reference Morgenstern, Lisabeth and Mecozzi 10 Educational strategies that focus on emergent evaluation of these common diagnoses may improve diagnostic accuracy, and may result in better patient outcomes by decreasing the time to administration of thrombolytic therapies.Reference Moeller, Kurniwan and Gubitz 11 , Reference Hansen, Fisher and Joyce 12 With this in mind, we sought to examine the level of clinical and academic stroke training within Canadian emergency medicine programs.
Methods
Study design and selection of participants
A two-page survey was sent by email to residency directors of all 30 English-speaking emergency medicine (EM) residency programs in Canada. This included the 11 Royal College (FRCPC) residency programs (5-year training) and the 19 College of Family Physicians of Canada Enhanced Training [CCFP(EM)] residency programs (3-year training). Residency directors were pre-notified of the need for a survey on this topic prior to distribution, and asked for input. Residency directors were then emailed up to six times over the period of April through September 2011. The survey was distributed as an attachment and respondents returned completed surveys directly to a research assistant. No incentive was provided.
Survey content
The survey was designed to determine the level of clinical and academic stroke training among Canadian EM residency programs. The survey instrument was generated by the research team, consisting of three emergency physicians (a content expert in stroke; two CCFP(EM) Program Directors) and a stroke neurologist. The survey instrument was pilot tested on emergency physician clinician researchers within the Department of Emergency Medicine, at the University of British Columbia.
Responses were requested regarding the number of residents within each program and the trainee intake into the program for July 2011. From a clinical standpoint, the survey requested information about mandatory and elective rotations in general neurology, stroke neurology, radiology, neuroradiology, and cardiology. Residency directors were asked if their trainees trained in hospitals that administered thrombolysis for acute ischemic stroke, if they did so under emergency physician supervision, and if they were required to lead stroke teams. Academic stroke training questions asked respondents about the total lecture hours per year and, specifically, lecture hours devoted to acute stroke, thrombolysis in acute stroke, and neuroradiology. Residency directors were asked to report total hours of oral examination and how much of this time was devoted to the management of acute ischemic stroke, the use of thrombolytics in acute ischemic stroke, and the management of TIA.
Data analysis
A descriptive analysis was performed. Means, standard deviations (SDs), and proportions with 95% confidence intervals (CIs) are reported.
Results
Program response rates and demographics
A total of 16 responses were received, representing 20 EM residency programs across Canada (RR: 20/29=69%). Nine FRCPC programs responded (RR: 9/11=82%), and 11 CCFP(EM) programs responded (RR: 11/18=61%). FRCPC programs had an average of 5 new residents per year, with a total of 25 in the program over all five years of residency. CCFP(EM) programs also accepted an average of five new residents per year, ranging in size from three to nine.
Clinical stroke training (Table 1)
Despite the fact that 100% of respondents trained residents in facilities that administered thrombolysis for stroke, a minority of programs offered clinical training in stroke. In addition, only 1/11 (9%) CCFP(EM) programs and 0/9 FRCPC programs had residents act as stroke team leaders.
Clinical stroke and general neurology training in EM residency programs
Mandatory general neurology rotations were present in 3/9 (33%) FRCPC and 0/11 CCFP(EM) programs. More specific mandatory stroke neurology rotations were offered at 2/9 (22%) FRCPC and 0/11 CCFP(EM) programs. An option of general or stroke neurology electives were available in 4/9 (44%) FRCPC programs and 1/11 (9%) CCFP(EM) programs, with a mean of 3.5 weeks and 4 weeks, respectively. By comparison, 9/9 FRCPC (mean 7 weeks) and 10/11 (91%) CCFP(EM) (mean 4 weeks) programs have a mandatory cardiology rotation.
Mandatory radiology rotations were present in 1/9 (11%) FRCPC and 0/11 CCFP(EM) programs. More specific neuroradiology electives were mandatory in 1/9 (11%) FRCPC programs (mean 4 weeks) and 0/11 CCFP(EM) programs. Electives in either general or neuroradiology were offered to trainees in 5/9 (55%) of FRCPC and 3/11 (27%) CCFP(EM) programs with mean lengths of 4 and 2.5 weeks, respectively.
Academic stroke training (Table 2)
Acute ischemic stroke was reported as a seminar topic comprising a mean of three lecture hours per year among 100% of responding programs. All responding FRCPC programs required oral examinations on the treatment and management of acute ischemic stroke and TIA, whereas only 7/11 (64%) and 8/11 CCFP(EM) programs required oral examinations on these topics, respectively. Didactic teaching and oral examinations on thrombolysis in acute stroke was reported in 8/9 FRCPC programs and 5/11 CCFP(EM) courses. Neuroradiology lectures occurred in 8/9 FRCPC (mean 3.75 hours) and 6/11 CCFP(EM) (mean 2.8 hours) programs.
Didactic stroke training in EM residency programs
Discussion
Our study highlights that formal stroke education in Canadian emergency medicine residency programs is limited. A minority of residency programs have mandatory clinical rotations in general neurology, stroke neurology, and neuroradiology. The majority of teaching around stroke and TIA is primarily academic, in the form of lectures and oral examinations, and yet even that is limited. In addition, there are further disparities in the quantity of training dependent on the route of training.
The proposition “time is brain” highlights the loss of nervous tissue that occurs in ischemic stroke in the absence of emergent evaluation and prompt institution of therapy. The diagnostic challenges faced by emergency physicians and trainees in early identification and management of stroke has been well established.Reference Pope and Edlow 8 - Reference Morgenstern, Lisabeth and Mecozzi 10 Further, the management of acute TIA is time-sensitive and complex, and without formal training in diagnosis, risk stratification, and management, it represents a significant missed opportunity to prevent stroke.Reference Rothwell and Warlow 2 , Reference Schrock, Glasenapp and Victor 13 Additionally, misdiagnosing a patient with TIA has significant implications (e.g., patient anxiety, radiation exposure due to imaging, and increased health care costs). Educational strategies that focus on emergent evaluation of these common diagnoses may improve diagnostic accuracy, and may result in better patient outcomes by decreasing the time to administration of thrombolytic therapies, or by the application of proven therapies after a TIA to prevent stroke.Reference Moeller, Kurniwan and Gubitz 11 . Reference Hansen, Fisher and Joyce 12 As such, a larger emphasis on clinical stroke training during residency is warranted, as only a minority of residency programs are offering mandatory clinical rotations in general neurology, stroke neurology, and neuroradiology, with even fewer offering such rotations electively. As a solution, both the CCFP(EM) and FRCPC programs should provide more mandatory training in stroke for residents, through participation in stroke prevention clinics, in stroke units, and in the ED as stroke team leaders. Recognizing that the largest barrier to stroke training is the limited time within residency programs, it is imperative that emergency physicians are well trained for a such a time-sensitive and significant disorder as stroke. In contrast, almost all emergency medicine residency programs had mandatory rotations in cardiology with, at minimum, four weeks of training.
Our study highlights that the predominant mode of formal stroke training in Canadian emergency medicine programs is academic, using a combination of lecture and oral examinations. Only 1% of lecture time was devoted to stroke and TIA within the emergency medicine residency programs, despite neurologic emergencies being 5% of all presenting complaints to EDs. With the rapidly evolving nature of the stroke field, and its significant morbidity and mortality, it may be beneficial to emergency residents to have a larger portion of academic time devoted to stroke evaluation and management. In addition, as simulation is incorporated more into emergency training, it is imperative to expose residents to simulated stroke scenarios during residency.
Informal stroke training does occur during emergency medicine rotations.Reference Stettler, Jauch and Kissela 14 It is in this format that emergency medicine preceptors likely provide the majority of stroke training for emergency medicine residents. However, in larger centres, where many emergency medicine residents are trained, stroke teams and neurology services often provide much of the emergent care, leaving emergency medicine trainees out of the thrombolysis decision-making process.
Limitations
As with any survey, there are multiple sources of bias that may influence the results and conclusions. Our survey was conducted in English; therefore, this survey reflects only the training that is provided in the non-Francophone programs. Only five of 30 programs are French-speaking; this was not expected to introduce significant bias, as similar training is reported between English-speaking and Francophone programs. 15 In addition, this was an email survey; this may have contributed to a lower response rate despite the targeted and frequent contacts.
Conclusion
Currently, formal training in stroke and TIA in Canadian emergency medicine residency programs is limited. The most common method of training is through academic lectures. Only a limited number of Canadian emergency residency programs offer either mandatory or elective clinical rotations in stroke neurology and neuroradiology. As emergency medicine takes on more responsibility in the acute management of stroke and TIA, it is paramount that future emergency physicians have adequate training during residency. Enhanced training opportunities during residency and as fellowships should be implemented.
Competing Interests: Dr. Harris: Bayer (consulting), Pfizer (consulting), ESD Stroke Rehabilitation Inc. (Director); Dr. Teal: SanofiAventis (consulting, lecture), Bristol-Myers Squibb (consulting, lecture), Boehringer Ingelheim (consulting, lecture), Bayer (consulting). No other conflict of interests declared. This paper was presented at the Canadian Association of Emergency Physicians Annual General Meeting, Vancouver, BC, June 2013.
