Weighing the gold standard: The breadth of emergency medicine core content covered by textbooks

Abstract

Background

Textbooks are often considered the criterion standard in medical education, but there is a growing preference for free open‐access medical education (FOAM) content among learners. Despite FOAM's appeal, these resources often fall short in covering core content as comprehensively as the American Board of Emergency Medicine's 2019 Model of the Clinical Practice of Emergency Medicine (MCPEM), thereby sustaining the recommendation for textbook use. However, textbooks have limitations, such as how quickly content can become outdated. Notably, there is no evaluation of the comprehensiveness of emergency medicine (EM) textbooks in the literature.

Methods

This observational cross‐sectional study compared Rosen's Emergency Medicine: Concepts and Clinical Practice 10th Edition (Rosen's) and Tintinalli's Emergency Medicine: A Comprehensive Study Guide 9th Edition (Tintinalli's) with the MCPEM subtopics. Each textbook chapter was reviewed for content alignment with MCPEM subtopics. The primary outcome was the proportion of MCPEM subtopics covered by each textbook. Secondary outcomes included the count of chapters covering each topic and their distribution relative to the core content weighting in the ABEM National Qualifying Examination (NQE).

Results

Rosen's covered 95.3% of MCPEM subtopics (837 unique subtopics), and Tintinalli's covered 94.5% (826 unique subtopics). Both textbooks overrepresented topics like toxicology and psychobehavioral disorders compared to their weighting in the NQE. Relatively underrepresented topics included environmental disorders, cardiovascular disorders, renal and urogenital disorders, and traumatic disorders in Rosen's and other core competencies and cardiovascular disorders in Tintinalli's. The textbooks varied significantly in coverage of certain topics.

Conclusions

Both Rosen's and Tintinalli's comprehensively cover MCPEM subtopics, with some discrepancies in topic representation compared to the NQE. While textbooks offer depth and breadth, they may not fully align with the NQE content distribution. A diversified approach to EM education, combining traditional textbooks and FOAM resources may be required for comprehensive learning.

INTRODUCTION

Textbooks are often considered the criterion standard in medical education, but recent trends show a shift in learner preferences to digital learning resources. ¹ , ² This movement toward free open‐access medical education (FOAM) has allowed rapid dissemination and broad accessibility of information, while narrowing the knowledge translation gap often cited as a drawback of print‐based resources. ³ Emergency medicine (EM) residents now use FOAM more often for their core learning than textbooks. ⁴ , ⁵ , ⁶

FOAM has faced criticism for its potential lack of rigor in peer review, absence of central oversight, and perceived incompleteness in content coverage. ¹ , ² , ³ Stuntz and Clontz ⁷ evaluated the breadth of EM core content covered in FOAM resources and found that, when compared to the American Board of Emergency Medicine's Model of the Clinical Practice of Emergency Medicine (MCPEM), a year of FOAM posts covered 71.5% of the topics outlined by the MCPEM. Similarly, Grock et al. ¹ examined the most impactful FOAM content as determined by the Social Media Index, a metric for FOAM analogous to an impact factor for medical journals, over a 12‐month period and found an overrepresentation of cardiology and neurology topics and a lack of coverage of psychobehavioral; obstetrics and gynecology; and head, ears, eyes, nose, and throat topics.

These findings prompt continued recommendations for the use of textbooks as learning resources, ¹ , ³ yet there remains a lack of thorough investigation into how well EM textbooks align with the MCPEM. This study seeks to determine the comprehensiveness of EM textbooks in covering topics outlined in the MCPEM, providing a critical comparison with the often used but less traditional FOAM resources.

METHODS

Study design

In this observational cross‐sectional study, we evaluated the content of two widely used EM textbooks: Rosen's Emergency Medicine: Concepts and Clinical Practice 10th Edition (Rosen's) and Tintinalli's Emergency Medicine: A Comprehensive Study Guide 9th Edition (Tintinalli's). ⁸ , ⁹ , ¹⁰ Our methodology aligned with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines and was classified as non‐human subjects research by the Stanford University Institutional Review Board. ¹¹ Our core objective was to compare the coverage of EM topics in these textbooks against the American Board of Emergency Medicine's 2019 Model of the Clinical Practice of Emergency Medicine (MCPEM). ¹² We excluded the category of “signs, symptoms, and presentations” from our analysis due to the frequency these topics are mentioned in textbooks.

Data gathering process

For data collection, we followed the methodology used in a prior study that evaluated blog content. ⁷ We compared the content of each textbook with the topics listed in the MCPEM. We completed keyword searches of digital editions for each MCPEM subtopic, including relevant synonyms and related terms. One author (CP) conducted the searches, and each identified section was read thoroughly to determine if it aligned with the MCPEM subtopic. Chapters were credited with covering a subtopic if they contained at least one sentence explicitly discussing the subtopic that directly informed about its implications, context, or mechanisms. Simply mentioning a keyword or related term without substantive context or explanatory detail did not qualify as coverage. This ensured that each credited mention provided meaningful information about the subtopic. Chapters could get credit for covering multiple MCPEM subtopics. Ambiguous or unclear sections were discussed with a second author. Three other study authors (AN, AO, CN) independently reviewed a random selection of 5% of subtopics to verify the chapters that covered these subtopics. Weighted kappa calculations showed substantial agreement between reviewers (κ = 0.69 for Rosen's and κ = 0.74 for Tintinalli's).

Outcome indicators

The primary outcome of our study was the overall proportion of MCPEM subtopics covered by each textbook. As secondary outcomes, we looked at the number of chapters covering each topic and their comparative representation against the core content weighting in the ABEM National Qualifying Examination (NQE). ¹³

Data analysis

We calculated descriptive statistics and 95% confidence intervals (CIs) for the proportion of coverage of each MCPEM topic. To ascertain the distribution of topic in the textbooks, we tallied the chapters covering each subtopic and used the total count of all topics in a given textbook as the denominator. This method allowed us to understand the relative emphasis each textbook placed on different EM topics.

RESULTS

In Rosen's, we identified 9432 instances covering 837 unique subtopics, and in Tintinalli's, 10,018 instances covering 826 unique subtopics. Compared to the 878 unique subtopics listed in the 2019 MCPEM, Rosen's covered 95.3%, and Tintinalli's covered 94.5%. Subtopics not identified as being covered are listed in Appendix S1.

Table 1 and Figure 1 illustrate the aggregated representation of the MCPEM topics and the corresponding textbook coverage of these topics. The most frequently covered section in both textbooks was toxicologic disorders, representing 12.6% and 12.1% of total topics covered in Rosen's and Tintinalli's, respectively, despite accounting for only 4% of NQE content. Psychobehavioral disorders were also relatively highly covered in both Rosen's and Tintinalli's (4.9% and 4.8%), more than twice the 2% they represent on the ABEM examination.

TABLE 1.

Topic coverage of Rosen's Emergency Medicine, Tintinalli's Emergency Medicine, and American Board of Emergency Medicine National Qualifying Exam.

Topic area	ABEM NQE percent (%)	Rosen's Emergency Medicine			Tintinalli's Emergency Medicine
		Total chapter count for all subtopics within topic	Topic representation as percent of total (95% CI)	Difference from ABEM NQE (%)	Total chapter count for all subtopics within topic	Topic representation as percent of total (95% CI)	Difference from ABEM NQE (%)
Abdominal and gastrointestinal disorders	7	622	6.59% (6.09%–7.10%)	−0.41	651	6.50% (6.02%–6.98%)	−0.50
Cardiovascular disorders	10	614	6.51% (6.01%–7.01%)	−3.49	744	7.43% (6.91%–7.94%)	−2.57
Cutaneous disorders	3	259	2.75% (2.42%–3.08%)	−0.25	389	3.88% (3.50%–4.26%)	+0.88
Endocrine, metabolic, and nutritional disorders	5	598	6.34% (5.85%–6.83%)	+1.34	598	5.97% (5.51%–6.43%)	+0.97
Environmental disorders	2	104	1.10% (0.89%–1.31%)	−0.90	58	0.58% (0.43%–0.73%)	−1.42
Head, ear, eye, nose, throat disorders	4	340	3.60% (3.23%–3.98%)	−0.40	412	4.11% (3.72%–4.50%)	+0.11
Hematologic and oncologic disorders	3	427	4.53% (4.11%–4.95%)	+1.53	470	4.69% (4.28%–5.11%)	+1.69
Immune system disorders	2	308	3.27% (2.91%–3.62%)	+1.27	281	2.80% (2.48%–3.13%)	+0.80
Systemic infectious disorders	7	585	6.20% (5.72%–6.69%)	−0.80	621	6.20% (5.73%–6.67%)	−0.80
Musculoskeletal disorders (nontraumatic)	3	394	4.18% (3.77%–4.58%)	+1.18	389	3.88% (3.50%–4.26%)	+0.88
Nervous system disorders	6	469	4.97% (4.53%–5.41%)	−1.03	524	5.23% (4.79%–5.67%)	−0.77
Obstetrics and gynecology	3	263	2.79% (2.46%–3.12%)	−0.21	352	3.51% (3.15%–3.87%)	+0.51
Psychobehavioral disorders	2	461	4.89% (4.45%–5.32%)	+2.98	481	4.80% (4.38–5.22%)	+2.80
Renal and urogenital disorders	3	204	2.16% (1.87%–2.46%)	−0.84	266	2.66% (2.34%–2.97%)	−0.34
Thoracic–respiratory disorders	7	574	6.09% (5.60%–6.57%)	−0.91	582	5.81% (5.35%–6.27%)	−1.19
Toxicologic disorders	4	1189	12.61% (11.94%–13.28%)	+8.61	1215	12.13% (11.49%–12.77%)	+8.13
Traumatic disorders	9	654	6.93% (6.42–7.45%)	−2.07	847	8.45% (7.91%–9.00%)	−0.55
Procedures and skills integral to the practice of EM	8	1036	10.98% (10.35%–11.61%)	+2.98	1027	10.25% (9.66%–10.85%)	+2.25
Other core competencies of the practice of EM	2	331	3.51% (3.14%–3.88%)	+1.51	111	1.11% (0.90%–1.31%)	−0.89

Note: Examination total does not add up to 100% due to exclusion of signs, symptoms, and presentations.

Abbreviation: ABEM NQE, American Board of Emergency Medicine National Qualifying Examination.

FIGURE 1.

Topic coverage of Rosen's, Tintinalli's, and the American Board of Emergency Medicine National Qualifying Exam.

Environmental disorders were the least covered topics in both textbooks (1.10% in Rosen's and 0.58% in Tintinalli's), significantly less than on the NQE (2% of content). Other topics with relatively low coverage in Rosen's were cardiovascular disorders (6.5%), renal and urogenital disorders (2.2%), and traumatic disorders (6.9%). In Tintinalli's, other core competencies of the practice of EM (1.1%) and cardiovascular disorders (7.4%) had relatively low coverage.

The textbooks significantly differed in their coverage of five topic areas: environmental disorders (Rosen's 1.1%, 95% CI 0.89%–1.3%; Tintinalli's 0.58%, 95% CI 0.43%–0.73%), other core competencies of the practice of EM (Rosen's 3.5%, 95% CI 3.1%–3.9%; Tintinalli's 1.1%, 95% CI 0.90%–1.3%), cutaneous disorders (Rosen's 2.8%, 95% CI 2.4%–3.1%; Tintinalli's 3.9%, 95% CI 3.5%–4.3%), traumatic disorders (Rosen's 6.9%, 95% CI 6.4%–7.5%; Tintinalli's 8.5%, 95% CI 7.9%–9.0%), and obstetrics and gynecology (Rosen's 2.8%, 95% CI 2.5%–3.1%; Tintinalli's 3.5%, 95% CI 3.2%–3.9%).

DISCUSSION

The transition from traditional textbooks to FOAM, as observed in recent years, highlights the evolving and increasingly digital elements of medical education. Our study aimed to address the comprehensiveness of EM textbooks, given recent concerns that FOAM may lack the breadth that textbooks provide. Both Rosen's and Tintinalli's provide extensive coverage of MCPEM subtopics, with Rosen's at 95.3% and Tintinalli's at 94.5%. These high percentages reaffirm the enduring value of textbooks as a fundamental resource in EM education.

However, neither textbook provided complete coverage of all content and we observed an imbalance of topic distribution compared to their representation on the NQE. Both textbooks showed a higher representation of topics like toxicology and psychobehavioral disorders. On the other hand, topics like environmental disorders were underrepresented. This disproportionate coverage suggests that while textbooks may be more comprehensive in terms of sheer topic count, there are still differences in topic selection and curation.

Although textbooks appear to be more comprehensive and less skewed in distribution than FOAM resources, they are not without their limitations. Textbooks can be costly and voluminous, requiring considerable time to read. In the context of EM, where quick access to information is often needed, textbooks, even in their digital forms, are not always the most practical for rapid reference. Furthermore, the static nature of textbook content means that they may not be as current as frequently updated digital resources.

Acknowledging these limitations is crucial. No single resource, whether a textbook or a digital platform, is without its drawbacks. An effective educational strategy should involve critical evaluation of various resources, encouraging learners to consult multiple sources and synthesize information. Educators can support this by creating diverse reading lists that include both print and digital materials and teaching critical appraisal skills during residency. Innovations like journal clubs focused on open educational resources are emerging to enhance these skills. ¹⁴ Adopting rigorous metrics and frameworks for online resources—and potentially developing new ones for textbooks—can guide this critical analysis. ¹⁵ In EM, where knowledge and best practices are constantly evolving, these skills are essential.

LIMITATIONS

Our study focused on the coverage of topics but did not delve into the depth or quality of the content provided, including the credentials of authors. The depth of content is equally crucial for robust medical education, and future research should explore this aspect. Furthermore, while our study provides a snapshot of the comprehensiveness of these textbooks, it does not address the dynamic nature of medical knowledge and the potential need for frequent updates, an area where FOAM may have an advantage. We chose to use chapters as the unit of analysis for this study as this was the closest analog to different blog posts; however, a different unit such as page space or word count may yield different results. Finally, although the MCPEM is a representation of topical knowledge in EM, there is likely no truly comprehensive list of all of EM knowledge.

CONCLUSIONS

Our study shows that Rosen's Emergency Medicine: Concepts and Clinical Practice 10th Edition and Tintinalli's Emergency Medicine: A Comprehensive Study Guide 9th Edition are nearly comprehensive in covering the American Board of Emergency Medicine's Model of the Clinical Practice of Emergency Medicine subtopics. While free open‐access medical education has its advantages in terms of rapid knowledge dissemination, the depth and breadth of conventional textbooks should not be discounted. A blended approach, utilizing both free open‐access medical education and textbooks, may be the most effective strategy in emergency medicine education, ensuring both breadth of knowledge and up‐to‐date clinical information.

AUTHOR CONTRIBUTIONS

Carl Preiksaitis conceived of the study and designed analysis. Carl Preiksaitis, Amana Nawaz, Alaa Ousta, and Cassandra Mackey collected data. Carl Preiksaitis completed data analysis. All authors participated in the drafting of the manuscript, contributed substantially to its revision, approved the final version of the manuscript, and agree to be accountable for their contributed work. Carl Preiksaitis takes responsibility for the paper as a whole.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Appendix S1.

Preiksaitis C, Nawaz A, Ousta A, Mackey C. Weighing the gold standard: The breadth of emergency medicine core content covered by textbooks. AEM Educ Train. 2024;8:e10994. doi: 10.1002/aet2.10994