Status of AcademicEmergency Medicine

in the U.S.A.

Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine

Uniformed Services University of the Health Sciences Clinical Professor of Emergency Medicine

George Washington UniversityBethesda, Maryland, U.S.A.

Current Status of Academic Emergency Medicine in the U.S.A. : Lecture Outline

Provide updates on the current status of U.S. :–Emergency Medicine (E.M.) in general–E.M. residency programs–E.M. training for medical students–Society for Academic Emergency Medicine (SAEM)–E.M. Research–Opportunities for international E.M. collaboration

General Importance of E.M. in the U.S.A.

E.M. is the first specialty to develop directly due to demand by the public–Other specialties are defined by anatomic region, particular type of disease, or particular age group of patients

E.M. encompasses all types of medical & surgical problems and all age groups

E.M. provides "safety net" in the national health care system for patient access to unscheduled care

Aspects of E.M. Which Benefit Other Medical Specialties in the U.S.A.

Allows other specialists to concentrate on their areas of expertise & interest

Decreases need for other specialists to be physically present in the hospital

Permits patients to be promptly evaluated when presenting at times inconvenient for other specialists

Allows effective screening of patients for hospital admission

Beneficial Efficiency Effects of E.M. on the U.S. National Health Care System

Prompt evaluation of emergenciesCompletion of diagnostic workups in single visits

Reducing admission rates to inpatient services

Limiting need for interhospital transfersAllowing coordination of care by other specialists for patients with multiple medical problems

Benefits of E.M. to the General Public

Reassurance and confidenceConvenienceEnsured access to careEducation–Illness & injury prevention–Correct utilization of health care system–Appropriate followup care

Benefits of Having Specialty Residency Training in E.M.

Provides core of specialists to staff emergency departments (E.D.'s)

Provides physician leadership–E.D. administrators or managers–Prehospital care system directors–Coordinate outpatient & inpatient care

Ensures quality, depth, and uniformity of training for emergency care

Benefits of Training Other Specialty Residents in E.M.

Allows ability & confidence in managing basic emergencies

Familiarizes them with E.D. operations and needs

Improves working relationship with E.M. faculty & E.M. residents

Allows them to learn cost-effective use of ancillary tests

Benefits of Training All Medical Students in E.M.

Ensures exposure to proper emergency management of common conditions

Meets public expectation that all doctors should know basic emergency care

Encourages some of students to pursue E.M. residency training

Allows students to appreciate the knowledge, areas of expertise, & skills of the E.M. physicians

Some may develop interest in pursuing E.M. research projects

Unique Subjects to Teach Students and Residents in the E.D.

Cost-effective ancillary test orderingEfficiency in patient flowManaging multiple simultaneous patientsCoordinating prehospital and E.D. careFocused approach to medical problems

Minimum Basic Subjects to Teach Medical Students & Residents in the E.D.

Recognition of emergenciesAirway managementCPRFocused evaluation of :–Headache–Chest pain–Dyspnea–Abdominal pain–Fever

Suturing / wound care

General Structure of U.S. Recommended E.M. Training for 1st & 2nd Year Medical Students

E.M. faculty involvement with lectures on basic & applied physiology

Extracurricular lectures on clinical topicsExtracurricular "workshops" or "labs" :–Suture technique–Airway management–Blood drawing–Intravenous line placement–Splint & cast application–EKG interpretation–X-ray interpretation

General Structure of U.S Recommended E.M. Training for 3rd & 4th Year Medical Students

3rd year :–Observational elective in E.D. ( 2 to 4 weeks)–Elective in prehospital (ambulance) care

4th year :–1 month elective ( or required) in E.D.–1 month elective in Toxicology–1 month elective in prehospital care–Students interested in career in E.M. (applying to E.M. residency) should do 2 months of E.D. electives

General Recommended E.M. Training for Residents from Other Specialties

Internal Medicine, Family Practice :–1 month in 1st year, 1 month in 2nd or 3rd year

General or Orthopedic Surgery, Anesthesia, Otolaryngology :–1 month in first year

Obstetrics & Gynecology , Pediatrics :–1 month in 2nd or 3rd year

Radiology, Pathology, Psychiatry, Ophthalmology :–May NOT need an E.M. rotation

General Structure of U.S. E.M. Residency Programs

75 % of programs are PGY 1,2,315 % of programs are PGY 2,3,4–Require "rotating" or "transitional" internship first

10 % of programs are PGY 1,2,3,4A few programs are 5 year combined residencies (E.M. / pediatrics, E.M. / Medicine)

Must be accredited by national Residency Review Committee–Strict standards are same for all programs

General Structure of U.S. E.M. Residency Programs (cont.)

> 50 % of time (> 18 months) in program must be in the E.D.

Important "off-service" rotations :–Critical care units (pediatric, medical, surgical)–Trauma surgery–Pediatrics–Orthopedics–Anesthesia–Medicine / cardiology

Non-E.D. E.M. Rotations Usually Included in E.M. Residency Programs

ToxicologyPre-hospital careAeromedical care (flying usually optional for residents)

Research1 to 2 months of electives

Career Options for E.M. Residents Graduating from U.S. ProgramsPrivate practice–Single hospital physician group–Multi-hospital physician group

Academic practice–Mix of clinical work, teaching, research–Usually work harder & get paid less

Administration–E.D. director–Prehospital system director

Additional fellowship trainingLocum tenens work

U.S. E.M. Fellowship Training Programs (following E.M. residency)

Emergency Medical Services (Prehospital care) : 1 to 2 yearsToxicology : 2 years (separate subspecialty certification)Pediatric E.M. : 2 yearsE.M. Research : 1 to 2 yearsE.M. Administration : 1 yearE.M. Education : 1 yearHyperbaric Medicine : 1 yearSports Medicine : 1 to 2 yearsCritical Care (Intensive Care) Medicine : 1 to 2 yearsAeromedical Care : 1 yearInternational E.M. : 1 to 2 years (may include obtaining an M.P.H. degree)

Facility Requirements for U.S. E.M. Residency Programs

Patient census > 30,000 (total) per yearPediatric census 15 % or 4 months full time equivalentCritically ill / injured patients : at least 4 % of census or > 1000 per year

At least 2000 patient encounters per resident per yearAccredited medicine & surgery residencies must be at same clinical site

Must have offices for faculty & residentsStat lab results should be available in < 1 hourMust have at least 5 hours per week didactic instruction by faculty

Requirements for Residents in U.S. E.M. Training Programs

May not work > 12 hours continuously in E.D.May not work > 72 hours per weekMust have at least one day off in every 7 daysMust be relieved of clinical duties sufficient to attend at least 70 % of scheduled conferences

> 50 % of rotations & clinical time must be in E.D.Must keep a procedure logbookMust have followup information on admitted patientsMay not be supervised by resident physicians from specialties other than E.M. when in the E.D.

Faculty Requirements for U.S. E.M. Residency Programs

Department chief must have :–E.M. board certification, administrative & clinical E.M. experience, academic achievement, involvement in medical organizations, same authority as other institut\ional chiefs

Program Director must have :–E.M. board certification, > 3 years experience, be clinically active, be scholarly active

Teaching Faculty must have :–One per every 3 residents, 25 % of time protected for academic activities, some must do research, most must be E.M. board certified, must provide 24 hour a day E.D. coverage

Current Status of the Specialty of E.M. in the U.S.A.

Core component of U.S. health care system– > 100 million visits per year

Mature, respected specialtyIndependent specialty board exam : the American Board of Emergency Medicine (ABEM)–Subspecialty certification (pediatric E.M., toxicology, sports medicine)

Independent Residency Review CommitteePopular as career choice among medical studentsPopular with the public (thanks to TV)Extensive current research efforts

2005 Statistics on E.M. in the U.S.A.

135 residency programs 3978 residents enrolled > 22,000 ABEM certified E.M. physicians > 35,000 total E.M. physicians in practice > 22,000 American College of Emergency Physicians (ACEP) members

> 5000 SAEM members4750 E.D.'s

Background of E.M. Considered as a "Primary Care" Specialty

Current situation in the U.S. is that the government thinks more "primary care" physicians are needed

Goal is > 50 % of physicians in "primary care""Primary Care" defined as :–Pediatrics, Internal Medicine, Family Practice, Obstetrics & Gynecology

U.S. government is increasing political & financial support for primary care but decreasing it for specialty care

Status of E.M. in the U.S.A. as a "Primary Care" Specialty

E.M.'s struggle to achieve recognition as a distinct specialty has led to reluctance to be declared a "primary care" specialty

However, E.M. does provide a large portion of primary care in the U.S.

So most look on E.M. as a "special case" specialty deserving government support

E.M.'s only "deficiency" related to providing primary care is its lack of providing "longitudinal care"

Legislative Efforts by E.M. on Behalf of the Public

"Prudent layperson" laws to ensure access to care

Support for prehospital care systemsInjury preventionViolence controlMeasures to limit driving while intoxicatedPublic education

Social - Societal Problems in the U.S. Which E.M. is Trying to Correct

Interpersonal violence–Assaults–Gunshots–Homicide–Suicide–Spouse abuse–Child abuse–Elder abuse

Social - Societal Problems in the U.S. Which Result in Increased Need for E.M.

Tobacco smokingAlcohol abuse–Driving while intoxicated–Most common cause of serious vehicle accidents

–Violence / assaultsObesityLack of health insuranceChild and elder neglect

Current U.S. Government Pressures on the U.S. Medical Training System

Stimulus comes from the government wanting to spend less $ on health care :–Reduce number of residency positions–Reduce number of medical school graduates–Decrease number of foreign graduates in U.S. training programs–Require foreign graduates to return to their home country after training–Restrict government funding to support only 3 years of residency training per resident

The Society for Academic Emergency Medicine (SAEM)

Main U.S. organization devoted to promoting academic E.M. (specifically teaching and research)

Holds annual meeting (5 day duration) & 5 annual regional research presentation meetings

Publishes Academic Emergency Medicine journalMonthly newsletterHas 29 different committees, task forces, & interest groups (International is largest one)

> 500 research abstracts at annual meeting

Status of E.M. at U.S. Academic Medical Centers

About half of the 125 U.S. medical schools have E.M. as a fully independent academic department

In the other half, E.M. is usually a division of the Dept. of Medicine or Surgery (but is often defacto independent)

E.M. faculty often have greater clinical workload than other academic faculty

E.M. rotations for medical students are usually elective rather than required

Some of the Research Areas in Which E.M. Researchers Play a Leading Role

Fluid resuscitationCPRACLSAsthmaInjury preventionPain managementDisaster management

E.M. Peer - Reviewed Journals

U.S.A. :–Annals of E.M. (A.C.E.P.)–Academic E.M. (S.A.E.M.)–American Journal of E.M.–Journal of E.M. (C.A.E.P.)–Prehospital & Disaster Medicine (W.A.D.E.M.)–Prehospital Emergency Care–Pediatric Emergency Care–Emergency Medicine Clinics–Topics in E.M.–Journal of Wilderness & Environmental Medicine

E.M. Non-Peer Reviewed Journals

Emergency Medicine NewsJournal of Emergency Medical ServicesEmergency Medical ServicesAir Medical JournalJournal of Air Medical TransportEmergency Medicine

Current Status of Academic E.M.in the U.S.A. : Summary

E.M. occupies key role in U.S. health care system

E.M. provides potentially useful training for all medical students and for residents from other specialties

E.M. residency training is the standard for supplying physicians to staff E.D.'s

Despite current difficulties, the future for U.S. academic E.M. appears bright