OSRs not only gain a unique set of skills and knowledge from rotating in the ED but also contribute significantly to the productivity of academic EDs. They provide an extra corps of care providers, which is especially useful on EM conference days, when all EM residents are excused from weekly clinical duties to attend didactic sessions. Under the supervision of board-certified emergency physicians, OSRs function almost as well as EM residents. In a study comparing ED quality indicators on conference days and nonconference days, there was no difference in the number of diagnostic tests, consultations, and unscheduled return visits or in patient satisfaction scores. The presence of OSRs was, however, associated with slightly longer decision-to-admit times (333 vs 313 min for EM residents) and ED lengths of stay for admitted patients (490 vs 445 min for EM residents) [3]. The presence of OSRs may reduce the number and/or duration of shifts for EM residents, relieving some of the burden of clinical service and potentially avoiding trainee fatigue and improving overall group morale. OSRs represent a unique learner population for senior EM residents and attending physicians to practice teaching skills.

Team building is yet another advantage of incorporating OSRs into the ED workflow. Although this concept may be less tangible than staffing numbers and shift hours, building an institutional sense of camaraderie between the EM staff and OSRs can have enduring positive effects. The process of consultation and admission to OSRs will be likely more efficient and collaborative if the OSR has rotated through the ED. OSRs will receive calls, not from strangers, but from friendly colleagues, whom they know, have worked with, and trust.

In the international setting, where many EM educational and EM systems are currently in the early stages of development, encouraging residents from other specialties to rotate and work in the ED offers many significant benefits. First, given the early stages of development of many EM systems abroad, there is simply no alternative workforce available to staff the ED, and OSRs are required to fill the schedule. In the newly growing ED, OSRs should be provided a valuable experience with a strong focus on learner-centered education. This helps to instill in them a new respect for the emerging specialty of EM. Second, training OSRs in an ED with direct faculty-level oversight and support, which they may never have experienced before in their parent specialties, reveals to them the intricacies of EM practice and patient-centered care. Finally, it helps to create lasting relationships and an understanding among the new EM faculty, the OSRs, and their parent specialist faculty members, who themselves may never have been exposed to a fully functioning, EM faculty-staffed ED before. In this way, creating a rewarding rotation for OSRs can be seen as a developmental and political tool in EM systems development, in addition to a tool for solving workforce and educational issues.

In a survey of the US allopathic EM residency programs, conducted by Branzetti et al. [1], EM residency educators indicated that the three most important didactic areas to teach OSRs are resuscitation, trauma, and toxicology [1]. In a survey of 71 internal medicine residents, conducted by Kessler et al. [4], the greatest self-perceived deficits in EM core knowledge were in orthopedics, environmental emergencies, airway management, and ophthalmology.

Instructional models for OSR education are discussed in the following sections.

Clinical (Case-Based) Teaching

Clinical teaching is the primary modality used in the ED to teach all trainees while on shift. We define clinical teaching as the informal educational discourse between the teacher and the learner that follows each patient care scenario during an actual shift. With growing emphasis on competency-based outcomes for learning, clinical teaching provides the greatest opportunity to directly assess and improve learner competency. Teaching is tailored to each trainee’s level of knowledge and is intended to be directly relevant to active patient care issues. Learners receive immediate, formative feedback regarding their specific strengths and weaknesses. The sheer quantity of potential “teachable moments” using the clinical teaching approach is a definite advantage. If an OSR sees about two patients per hour during a typical 8-h shift, he or she will have more than 15 patient care encounters, each of which has multiple teaching points to discuss. The wide spectrum of ED cases provides a wealth of potential clinical learning opportunities for OSRs. To supplement this variability in clinical experiences, a targeted didactic program should be instituted.

Several drawbacks limit an OSR curriculum based solely on clinical teaching. Chief among these is the likelihood of a nonuniform educational experience. On a day-to-day basis, there exists an inherent unpredictability of patient presentations in the ED. This translates into OSRs receiving variable clinical exposure during EM rotations. It is impossible to guarantee that each OSR will encounter a set checklist of chief complaints and perform a list of specific procedures. Furthermore, the EM rotation can be greatly influenced by the ED type (e.g., community, academic, county, trauma center), patient demographics, ED census, and the presence of other learners (EM residents, medical students, other preprofessional students).

Another challenge to clinical teaching is the increasing demand on attending emergency physicians for optimizing patient throughput. The pressure to evaluate and manage patients with expediency leaves less time for discussing with learners and supervising them. This can lead to unidirectional, work-related communication (teacher to learner), which limits educational effectiveness. It can also lead to the inability to use bedside teaching (a subset of clinical teaching where teaching is conducted in the presence of the patient) as an effective instructional tool [6]. Chisholm et al. [7] found that only 3.6% of the resident’s ED shift involved an EM attending observing direct patient care. Without adequate time available for attending emergency physicians to observe the resident, instituting a culture of clinical teaching and feedback can be extremely difficult.

On-Shift Didactics

Some academic EDs excuse OSRs and other trainees from clinical duties for 15–60 min daily to attend a structured educational session. These sessions, often called teaching rounds, can consist of case-based discussions, chart reviews, skills workshops, or informal minilectures. Teaching rounds are modeled after similar sessions in other specialties, such as “morning report” or “noon conference.”

Teaching rounds offer several advantages. They provide daily protected educational time, targeted to teaching those who are already working clinically. These sessions also help to ensure a more consistent foundation of knowledge transfer regarding common ED presentations, treatment plans, and management dilemmas. Finally, providing a basic foundation of EM knowledge to OSRs with teaching rounds allows more advanced teacher–learner discussions during future clinical teaching scenarios.

The major disadvantage to this teaching approach as the sole educational technique for OSRs is the attending physician’s inability to directly assess each trainee’s performance in real time. Accurate evaluation of clinical acumen, interpersonal and communication skills, and decision making in the ED requires direct observation and feedback. Furthermore, it can be difficult for the attending physician to tailor teaching rounds to each trainee’s knowledge level because the entire discussion group has learners at different stages of training. Teaching round topics need to be planned in advance to ensure the transmission of specific learning points targeted at all levels of learners. Another major obstacle to instituting teaching rounds revolves around patient care responsibilities. Insufficient resources may preclude residents from being released from the clinical area, even for a brief time. Emergent care issues can arise at unpredictable times, potentially interrupting teaching rounds. This affects not only the residents but also the teaching physicians.

Formal Didactics

Although well-developed didactic curricula exist for all EM residents and most medical students, academic EDs use different approaches toward OSR didactics. The Branzetti survey found that among the US allopathic EM residency programs, 31% had no didactics for OSRs at all, 64% sent them to existing conferences intended for other learners (either EM residents or medical students), and only 5% had a dedicated curriculum [1]. Interestingly, almost two-thirds of the programs without didactics felt that no didactics were necessary for OSRs. The main advantage of sending OSRs to conferences intended for other learners is the possibility of some overlap in didactic subject matter with no extra resource required.

The main educational disadvantage of using formal sessions as the sole form of didactic education is that OSRs represent a heterogeneous population with different learning objectives. Internal medicine residents are unlikely to have the same learning objectives for their EM rotation as orthopedic residents, and both these groups are unlikely to share objectives with their EM counterparts or medical students.

Logistical and scheduling challenges also exist in releasing OSRs to attend formal didactic sessions. They may have competing conference obligations, such as their longitudinal outpatient clinics and their departmental lectures. Furthermore, with OSRs attending residency conferences, ED shift scheduling becomes difficult. EM residents are required to attend weekly conferences, leaving the ED to be staffed by EM attending physicians, midlevel providers (if available), and OSRs. Many EDs function less effectively without OSRs helping to offset the deficit in health care providers on EM conference days.

Perhaps, the most important point regarding formal didactic sessions for ED trainees (i.e., EM residents, OSRs, and medical students) is that the heterogeneity of learners almost necessitates heterogeneity in content. A single curriculum cannot be applied to all.

There is no single, ideal strategy for teaching OSRs in the ED. Each institution must balance the available resources in the ED, faculty time and availability, and specific needs of the OSRs.

Be a More Effective Clinical Educator

With the growing emphasis on outcomes-based assessment and competency in medical education, direct clinical observation, teaching, and feedback will likely play a greater role in the ED. For OSRs, clinical education should be tailored to the learner. Specific medical specialties have variable content overlap with EM. For instance, a transitional intern entering a dermatology residency will likely not have as strong an EM knowledge base as a categorical third-year resident in internal medicine bound for a cardiology fellowship.

OSRs play a crucial role in the ED, both as care providers and learners. Their educational experiences vary widely, depending on available resources, faculty time, and learning needs. Educating OSRs is often seen as a lower-priority task (after EM residents and medical students bound for EM), but advocating it as a departmental priority can have significant positive effects for both parties. Academic EM programs should give definite attention to efficient clinical teaching strategies and structured didactic curricula for OSRs. For newly emerging EM programs abroad, efforts at creating a stimulating, educational rotation for OSRs will greatly benefit current and future EM development.