Entering the workforce, an emergency physician (EP) must be prepared to care for “anyone, anything, anytime,” including the unique subset of patients who straddle the line between adult and pediatric care (1). Adolescents (aged 10-24 years) often present to emergency departments (EDs) for care; over 1,500,000 United States adolescents reported that they rely on emergency services for the majority of their medical needs (2,3). Despite the recent increase in pediatric EPs, 80%-90% of pediatric emergency patients are still treated by general practitioners outside of subspecialized academic centers (4).

Unfortunately, many EPs feel the lack of skills or clinical resources to comprehensively address adolescent health issues (5). In turn, adolescents often report that they feel uncomfortable or unsafe when attempting to access emergency care (6). Because many adolescents rely on emergency services for healthcare, improving treatment in EDs is critical in combating these concerns and reducing morbidity (7). Without appropriate training, EPs incur an increased risk of adverse outcomes due to missed diagnoses, delayed diagnoses, or age-inappropriate care.

Although the American Council for Graduate Medical Education provides direction on emergency medicine (EM) residency curriculum content, the coverage of pediatric topics varies among institutions. Popular EM educational guidelines, such as the Model for Clinical Practice of EM, are not intended to address how various complaints may present differently across the lifespan (8). One large Delphi study conducted in 2017 provided further guidance on key competencies within pediatrics to supplement the Model for Clinical Practice of EM, but it did not specifically address adolescents (4). In contrast, the Society for Adolescent Health and Medicine outlines a proposed adolescent medicine curriculum. While this curriculum is comprehensive and designed for outpatient care of adolescents by subspecialists, it is not intended for use by EPs in the acute setting (9). With limited recommendations and resources, it is difficult for directors of EM residency programs to ensure that critical topics in adolescent medicine are adequately covered in the didactic curricula (10). Because most EPs practice in general EDs, rather than in academic or pediatric EDs, resident training for adolescent care is critical for all EPs.

The goal of our study was to achieve expert consensus on the adolescent health competencies that should be mastered by EPs, and to determine which of such topics should be specifically included in a didactic curriculum. In order to achieve these objectives, we employed a modified Delphi method to elicit and consolidate expert opinion.

The Delphi method is a validated and widely utilized method of determining expert agreement on competencies and generating content validity for curriculum development (11). It is a powerful tool in its capacity to include geographically diverse experts while maintaining anonymity and a relatively low cost of implementation (11,12). Redcap software (REDCap Consortium) was used to send automated email invitations and administer online surveys (13,14). All procedures and materials were approved by the institutional review board at Baylor College of Medicine (IRB no. H-51071).

An overview of the Delphi process is depicted in Fig. 1. Sixteen invited experts participated in round 1, in addition to 8 community physicians, yielding a total panel size of 24 experts. Round 1 panelists had a diverse range of relevant specialties. Appendix 1 (https://doi.org/10.22470/pemj.2024.00955) details the composition of the panel in each round, which included nationwide physicians.

In round 2, the panelists evaluated a total of 26 topics, including the 23 that met consensus criterion in round 1 as well as additional 3 that were proposed by at least 2 panelists in round 1 (Table 1). Twenty-four of the 26 topics reached consensus as either a 4 or 5 on the 5-point scale to be included in a didactic curriculum. Two topics (“treat overuse injuries in adolescents” and “offer counseling on substance use cessation”) did not meet consensus criterion in round 2 (Table 1).

Finally, in round 3, a total of 17 panelists prioritized the most important topics. The following topics were most often selected as being integral to a didactic adolescent medicine curriculum for EM residents: 1) “manage a patient presenting after reported sexual assault,” 2) “accurately diagnose ovarian torsion,” and 3) “manage a patient presenting for symptoms of sexually transmitted infection (Table 2).”

No standard set of competencies or curriculum exists for EM residents on the care of adolescent patients (10). To our knowledge, this study is the first to specify which emergency adolescent care-related competencies should be included in a didactic curriculum for EM residents. Twenty-six unique topics were identified by the panelists. Given structural and time constraints, as well as the tremendous volume of material that must be covered during EM residency training, the panelists prioritized the most important topics. Based on our recommendations, directors of residency programs may modify their specific didactic offerings depending on their individual needs and resources.

The top 3 topics are related to sexual, reproductive, or genitourinary issues. Approaching these topics with adolescents is common but may be more uncomfortable than with adults, requiring a different approach. Open conversation and collaboration between patients and physicians are particularly consequential in the current landscape of rapidly changing legislation regarding limited reproductive care in many states in the U.S. In a future curriculum, it will be important to emphasize how to communicate when discussing sexual health topics with adolescents, such as navigating issues of consent and confidentiality for minor patients. Although the competency of “effectively tailor communication strategies to developmental level” was not frequently (12.5%) ranked in round 3, the panelists might feel that it was covered with greater specificity by other proposed topics, such as “manage a patient presenting for symptoms of sexually transmitted infection.”

“Manage a patient presenting for a mental health complaint” was chosen as a top priority by the panelists. This finding might be related to the reality that adolescent mental health in the U.S. has become an increasing concern in the last several years. Since the beginning of the coronavirus disease 2019 pandemic, the Centers for Disease Control and Prevention have reported the development of “an accelerating mental health crisis among adolescents (18).” Approximately 1 in 4 adolescents will experience a psychiatric disorder that results in severe impairment, and about half of all lifetime cases of psychiatric illness begin by 14 years of age (19,20). Because mental health disorders often present differently in adolescents, it is crucial to address these concerns specifically in the population. Adolescents are also at increased risk for the onset of many mental health conditions, requiring providers to appropriately recognize a previously undiagnosed condition. Meanwhile, fewer physicians selected related topics such as “treat medical complications of eating disorders” or “manage a patient presenting with non-suicidal self-injury.” One possible explanation for this finding may be that panelists believed these specific skills were not significantly different than those needed to treat adults. Alternatively, panelists may have considered these topics to be included in the broader ability to “manage a patient presenting for a mental health complaint.”

Only 2 of 26 topics met the consensus criterion in round 1, but not in round 2 of the Delphi process. This discrepancy might be attributed to a slight difference in panel composition between the rounds. It may also have been that some panelists felt EPs should be competent in these areas (round 1) but not that they were important to cover specifically in a didactic curriculum (round 2). Nevertheless, this level of concordance is satisfactory and serves to indicate the reliability of our findings (21).

This study has its limitations. A low response rate is common in conducting a Delphi process, which we attempted to mitigate by sending 2 rounds of follow-up email reminders to invite experts (22). EPs showed a high response rate, perhaps because they felt the material was most relevant to their own practice and teaching responsibilities. As in all Delphi studies, it is possible that a different composition of panelists would lead to a different result, though this panel composition is representative of EPs treating adolescents in EDs. Finally, we recognize that a didactic adolescent medicine curriculum may be insufficient to fully address this particular educational gap, which likely contributes to the discomfort of both physicians and adolescents in EDs. However, it is beyond the scope of this study to suggest additional simulation or clinical training opportunities.

In this modified Delphi process, our expert panel agreed on a set of 26 competencies in adolescent medicine to include in a didactic curriculum for EM residents and prioritized the top 10 of these findings. In the future, this guidance can supplement that provided by the EM Model of Clinical Practice to offer a content blueprint for the development of a curriculum specific to emergency adolescent care. Considering the unique needs of the adolescent population and the current lack of specific guidance, our findings provide a crucial step in the effort to adequately prepare EPs for the unique challenges of treating adolescents.