The emergency department is one of the most challenging clinical settings in healthcare. The nature of this environment demands that physicians combine clinical knowledge, procedural skills, situational awareness, and rapid communication to treat undifferentiated and potentially unstable patients. These demands become particularly important in tertiary-care hospitals, where patients are often acutely unwell, and young doctors are directly involved in initial assessment and management.

The period immediately following undergraduate medical education and training, and before the start of postgraduate training, is a vulnerable time for the development of clinical competence. House Officers are expected to apply theoretical learning to bedside decision-making. Still, this exposure to emergency medicine may vary and is influenced by the local rotation structure, supervision and availability of skills training. By contrast, residents typically have more formal clinical responsibilities, teaching, resuscitation training, and repeated exposure to emergency case management. Previous research on procedural confidence has shown that clinicians' confidence varies with grade and exposure, thereby justifying a study of competence across various training levels [1].

Training in emergency medicine in LMIC has also been described as inconsistent and highly heterogeneous in training programs, faculty availability, and simulation resources [2]. There has been an increase in formal EM training in Pakistan over the past decade; however, the number of training programs and trained emergency physicians remains insufficient to meet national needs [3].

The preparedness of House Officers and early trainees is especially significant, as they are often the first physicians to examine an unstable patient in the emergency department and are subject to overcrowding in that setting.

The quality of procedural confidence and clinical knowledge plays a pivotal role in emergency care. Knowledge without procedural competence might delay life-saving procedures, while confidence without knowledge might foster unsafe independence. In the same way, poor triage skills may impact patient flow, result in under- and/or overtriage, and potentially contribute to delayed care. Research on structured triage systems, such as the Emergency Severity Index, shows that with training and standardized protocols, triage can be valid and reliable [4]. Simulation-based emergency medicine education has also been found to be an effective educational intervention for enhancing learner performance and satisfaction, suggesting its value [5].

The purpose of the present study was to compare House Officers and Residents in a variety of areas of emergency medicine preparedness. The aim was not only to assess whether a competency gap exists, but also whether exposure to ACLS, training in triage and simulation training, as well as experience in the emergency department, are correlated with increased clinical readiness. The results will be used to help inform curriculum improvements in house-job training and early postgraduate emergency medicine training.

1.1 Research objective

The primary objective of this study was to compare procedural confidence and clinical knowledge in emergency medicine between House Officers and Residents in tertiary-care settings. Secondary objectives were to compare ACLS readiness, triage competency, simulation exposure, and overall clinical readiness between the two groups and to examine predictors of clinical readiness.

1.2 Research hypothesis

It was hypothesized that Residents would demonstrate higher procedural confidence, clinical knowledge, ACLS readiness, triage competency, and overall clinical readiness than House Officers. It was further hypothesized that greater emergency department exposure and higher competency domain scores would be positively associated with overall clinical readiness.

2. Literature Review

A blend of didactic learning develops competence in emergency medicine, supervised clinical exposure, deliberate practice, and structured feedback. The first few clinical years are then integral to preparing the student for the job. Ericsson's model of deliberate practice suggests that mastering a skill requires repeated practice of challenging tasks, feedback, and incremental improvement [6]. A practical example is a procedure performed rarely but with high stakes, and thus needs to be practiced before being performed independently, such as in an emergency medicine setting.

There has long been recognition of the importance of procedural confidence as a dimension of clinical training. They also discovered that confidence levels in practical procedures differ among doctors by grade, and that doctors' training programs should provide competence in procedures likely to be required in hospital practice [1]. This is an issue in emergency medicine because procedures (including airway maintenance, cardiopulmonary resuscitation, vascular access, wound management, and trauma assessment) must be performed in emergent situations.

Equally important is clinical knowledge, as it contributes to the ability to implement protocols promptly and to make evidence-informed decisions in emergency care. Junior doctors are expected to identify unstable presentations, commence early resuscitation, communicate effectively with senior colleagues, and prioritise investigation and treatment. Frontline junior doctors in resource-poor areas have been shown to be less well prepared in acute care skills such as airway management, resuscitation, trauma care and triage [7]. This is similar to gaps found in multiple studies across low- and middle-income countries (LMICs), which have reported non-comprehensive training programs and inadequate access to standardized training curricula [2].

Life-support training has been repeatedly highlighted as a priority. Although it was recommended that preregistration doctors should be able to provide advanced life support training, Phillips and Nolan have shown that this was not a uniformly offered component of medical schools' training curricula [8]. Research on resuscitation education also suggests that it needs to close the gap between what is known in guidelines and what is done in real life, using best practices in education [9]. Thus, ACLS and repeated resuscitation should be seen as important measures of readiness in emergency environments.

Another key area of competency is triage. Triage is not only a process for determining urgency but also can help direct the use of resources and may even have a direct impact on patient outcomes. The Emergency Severity Index has been tested and proven to be a reliable triage instrument in an emergency environment [4]. Triage performance, however, is not uniform across EDs, and the systematic review literature indicates that mistriage and lack of reliability still pose concerns [10]. The results confirm the need for structured training in triage and frequent testing of competency in early clinical training.

Simulation-based training is a hands-on approach to filling gaps in procedures, teamwork and emergency decision-making. Ten Eyck et al were able to illustrate that a randomized controlled trial of simulation-based emergency medicine curriculum positively affected medical student test performance and satisfaction [5]. Through simulation, students can perform in high acuity situations in a safe setting, get feedback and practice again without placing patients at risk. This will be of specific benefit to House Officers as the actual exposure they receive in the emergency may be variable and supervision may be variable.

Although of course there has been some evidence on procedural confidence, simulation, life-support education, and triage, there are fewer studies that have compared House Officers and Residents in the same tertiary-care setting. This comparison is crucial to understand if the competency gap is being caused by being in the training stage, exposure or educational opportunities. This study meets this need by reviewing several domains of emergency medicine at the same time and by correlating competency scores with clinical readiness.

3.1 Study design and setting

A comparative cross-sectional study design was used to assess emergency medicine preparedness among House Officers and Residents. The study settings were the emergency medicine, internal medicine, surgery, and critical care rotations in Pakistani tertiary-care hospitals. A cross-sectional design was suitable as the focus was to compare competency and readiness domains at a specific time between two training groups.

3.2 Study population and sampling

The study population consisted of junior doctors exposed to the ED. House Officers were defined as newly graduated doctors who were doing house job or internship rotations, while Residents were defined as postgraduates in the field of emergency medicine or related clinical specialties. Three hundred subjects (137 House Officers and 163 Residents) were provided. The subjects included doctors who had lived or worked in emergency-care situations.

3.3 Data collection instrument

Structured questionnaire was used to collect data. It consisted of demographic variables, training characteristics, prior exposure to an ED, ACLS certification, formal training in triage, simulation training, and five Likert scale domains. Twenty items each were used to measure procedural confidence, clinical knowledge, ACLS exposure/readiness, triage competency, training gap/curriculum need, and overall clinical readiness. Responses were given on a 5-point scale of "Agree" to "Don't Agree" (higher scores mean greater agreement) or "Not Sure" to "Very Sure" (higher scores mean greater confidence) or "Not Ready" to "Very Ready" (higher scores mean greater preparedness) based on the domain.

3.4 Operational definitions

Composite scores were derived by taking the mean of the items in each domain. Procedural confidence was defined as self-perceived ability to perform or to help with basic emergency procedures. The clinical knowledge was perceived ability in applying the principles of emergency medicine and guideline-based reasoning. The ACLS readiness was a measure of cardiac arrest management and cardiac arrest resuscitation algorithms. Triage competency was defined as the ability to prioritise patients based on the urgency. Clinical readiness included the general level of preparedness to manage common emergency situations and to be able to join effectively in emergency-care teams.

3.5 Ethical considerations

This study protocol needed institutional ethical approval prior to data collection. The participation was voluntary and informed consent of all participants required. The results were to be anonymous and confidentiality was to be adhered to during data handling and analysis. The specific IRB Approval Number should be placed before submitting.

3.6 Statistical analysis

Data were analysed in SPSS. Demographic and training variables were used to create descriptive statistics. Cronbach's alpha was used to determine the reliability of questionnaire domains. Independent-samples t-tests were performed to compare the means between House Officers and Residents. Categorical training exposures and readiness classification were compared using chi square tests. Differences between the emergency-department exposure categories was evaluated using one-way ANOVA. Pearson correlations were used to investigate the relationships among various clinical readiness and competency predictors. Various univariate and multivariate analyses were performed to determine independent predictors of general clinical readiness. A p-value of <0.05 was taken to be statistically significant.

The results are organized in a logical order starting with participant profile, then followed by group comparisons, categorical training exposure, emergency department exposure effects, correlation analysis and regression analysis. A comparison was made between House Officers and Residents with regard to emergency medicine competency as well as training-related factors and overall clinical readiness.

4.1 Participant characteristics

A total of 300 individuals were analyzed. 137 (45.7%) of the participants were House Officers, while 163 (54.3%) were Residents. Participants averaged 26.82 years of age (SD = 2.63) and 7.06 months of exposure to the emergency department (ED) (SD = 6.07). Those who participated came from emergency medicine, internal medicine, surgery, critical-care and other departments.

Table 1. Participant profile and training exposure.

4.2 Internal consistency

The internal consistency of all the items on the Likert scale was found to be acceptable to excellent with Cronbach's alpha statistics. Alpha coefficients were between .882 and .948 for clinical readiness and clinical knowledge, respectively, and suggested that the items in each domain represented coherent constructs and were suitable for composite-score analysis.

Table 2. Reliability coefficients for questionnaire domains

4.3 Descriptive statistics

Independent-samples t-tests showed statistically significant differences between House Officers and Residents on all of the primary competency domains. House Officers were not as confident as residents in procedural confidence, clinical knowledge, ACLS readiness, triage competency, clinical readiness, or overall competency index. The largest group difference was for the competency index, with Residents reporting a mean score of 3.90 and House Officers reporting a mean score of 3.12, t(298) = -19.16, p < .001, Cohen's d = 2.22.

Table 3. Group comparison of competency and readiness outcomes

Table 4. Categorical training exposure and readiness outcomes by group

Table 5. One-way ANOVA across emergency-department exposure categories

4.6 Correlation and regression analysis

Positive correlations were found between clinical readiness and procedural confidence, clinical knowledge, ACLS readiness, triage competency, overall competency index, and emergency-department exposure based on Pearson correlation analysis. There was the highest correlation with clinical readiness (r = 0.59, p < .001) followed by the competency index (r = 0.49, p < .001) and procedural confidence (r = 0.48, p < .001). There was a negative relationship between training gap/curriculum need and clinical readiness (r = -0.26, p < .001).

Table 6. Correlations with overall clinical readiness

A multiple linear regression model was then estimated to determine the predictors of clinical readiness. The model was statistically significant, F(4, 295) = 40.56, p < .001 and accounted for a variance of 35.5% in clinical readiness (adjusted R² = 0.346). The competency index proved to be the strongest risk factor in isolation for being clinically ready (B = 0.662, SE = 0.087, t = 7.58, p < .001). The group difference in readiness after adjusting for the competency index was not independently significant, indicating that differences in readiness between the groups were mostly accounted for by the underlying competency domains.

Table 7. Linear regression model predicting clinical readiness

A consistent and statistically significant competency gap between House Officers and Residents was identified in all major domains of emergency medicine in this study. Residents indicated increased procedural confidence, clinical knowledge, readiness for the ACLS course, triage skills, and clinical readiness. The results lent support to the main premise of the study, which was that the preparedness of postgraduate trainees is higher than that of doctors at house job stage in Emergency Medicine. The difference in the confidence of the procedures is clinically significant. The difference between the scores of residents and House Officers was huge, with a large effect size. This is similar to previous studies that indicate there are grade- and experience-related differences in procedural confidence [1].

In the field of emergency medicine, confidence is not a sign of competence but rather a careful interpretation of it. But when House Officers lack confidence, it could be due to limited exposure, to less practice, or to less supervised practice in undergraduates and interns, or to insufficient procedural teaching. The finding does therefore lend support to the introduction of structured house-job period sessions focused on procedural-skills. The residents were also found to have higher clinical knowledge scores. This disparity may be attributed to the repetitive exposure to emergency presentations, formal teaching in postgraduate training and more experience in following guideline-based emergency care. This is in line with training-needs studies carried out in frontline junior doctors, which found that there were areas of low levels of knowledge and low levels of acute management skills [7]. It also corresponds to evidence from low and middle income sites where curricula in emergency medicine are largely inconsistent and need to be better standardized [2].

There were significant differences in ACLS readiness and certification between the two groups. The majority of Residents and about half of the House Officers reported that they had been certified in ACLS. This is significant because training in life-support is a basic requirement for the job of emergency and acute-care work. Phillips and Nolan found that while basic and advanced life support training are important for preregistration doctors, they are not always delivered to them evenly during their training [8]. The present results indicate that the same concerns could be relevant for House Officers in the local tertiary care setting. Pre-rotation or early rotation mandatory ACLS training may thus be a feasible intervention.

The findings from the triage are also significant. House Officers were less likely to be competent on the triage and were less likely to categorize triage competently as the residents. The skill of triage is an impactful skill, as incorrect prioritization can be detrimental to providing care to unstable patients, or waste precious emergency resources. Structured systems for the assessment of triage severity, like the Emergency Severity Index, have been found to be valid and reliable in ED research, and triage-performance evaluations have consistently identified mis-triage and inconsistent reliability [4, 10]. Formal triage training should not be reliant on the informal exposure in the workplace; it should be a component of the orientation to the house and assessed regularly. In general, simulation training was much more prevalent among Residents than House Officers. Educationally relevant, this difference is that simulation-based emergency medicine curricula have been demonstrated to have a positive impact on learner satisfaction and test performance [5].

Simulations offer a safe environment to practice resuscitation, trauma assessment, teamwork and communication. House Officers might find simulation particularly useful because the scenarios are high acuity ones that could occur on routine rotations without warning. Higher competency and readiness scores were significantly related to exposure in the ED. The competency index and clinical readiness were highest with participants who have more than 6 months of exposure in the ED. This is in line with the idea of competence development through repeated clinical exposure and in line with the principle of deliberate practice [6]. But that's not always enough. If not supervised, feedbacked, and with structured aims, exposure can reinforce variable practice. Thus, bedside and simulation, direct observation, reflective feedback and competency-based assessment must be integrated into emergency rotations. To further elucidate this relationship, regression analysis was also used to analyze the data on training group and readiness.

The results of the bivariate comparisons showed that Residents had higher scores for readiness, but the group did not score differently after the competency index was added to the model. This implies that the gap between Resident and House Officer is there not so much because of their designation as much as it is due to the skills they have acquired through practice, exposure and training. From a practical perspective, the competency domains among House Officers may help to reduce the readiness gap. The results are applicable to medical training and hospital policy. First, it is necessary to make emergency medicine as a structured and compulsory training program of house jobs. Second, it is important that the junior doctors who are placed in the emergency room be certified in ACLS and trained in triage. Third, simulation should precede independent night-duty responsibilities. Fourth, competency assessment should incorporate both self-efficacy and objective assessment including Objective Structured Clinical Examinations, Direct Observation of Procedural Skills, or scenario-based triage assessment.

5.1 Limitations

Several limitations should be acknowledged. First, this design is cross sectional, therefore causal relationships can't be drawn. Second, the majority of outcomes consisted of self-reported responses on likert scales that could be subject to social desirability or confidence bias. Third, while multiple tertiary-care settings were included in the data set, results may not be directly applicable to smaller hospital settings, rural emergency departments, or hospital settings that differ in training formats. Fourth, procedural performance was not observed in the real world. Future studies should include objective measures like OSCEs, DOPS, simulation scoring and supervisor rated competence.

5.2 Recommendations

The study recommends the following: House Officers should be required to receive ACLS training prior to emergency postings, emergency medicine should incorporate structured triage teaching based on validated triage frameworks, emergency medicine should have simulation-based boot camps at the start of house job years, and competency assessment should be done periodically and emergency medicine should have supervised procedural-skills logs. Institutions should also design the minimum competence of house-jobs standardized learning outcomes of emergency medicine, so that the minimum competence is not only based on informal exposure.

This study shows a significant disparity between House Officers and Residents with regard to competency in the area of emergency medicine. Residents experienced increased procedural confidence, clinical knowledge, ACLS readiness, triage competency, and overall clinical readiness. The categorical analyses revealed that Residents were more likely to be certified in ACLS, complete formal triage training, have experienced simulation exposure, demonstrated adequate triage competency, and demonstrated adequate clinical readiness. Having been exposed in the ED was correlated with better competency scores; the overall competency index proved to be the most powerful predictor of clinical readiness through regression analysis. The results indicate that house job to residency transition is still a pivotal time in the training of emergency medicine. Enhancing house-job training with the provision of ACLS certification, structured triage training, and supervised emergency rotations, and simulation-based procedural practise, may better prepare junior doctors for house-job duties and better improve patient safety in the emergency setting. Future research needs to employ a longitudinal design with objective measures of performance to determine if these interventions decrease the competency gap over time.

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