Status of Academic Emergency Medicine in the U.S.A .

1. Status of Academic Emergency 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 University Bethesda, Maryland, U.S.A.

2. 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

3. 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

4. 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

5. Beneficial Efficiency Effects of E.M. on the U.S. National Health Care System • Prompt evaluation of emergencies • Completion of diagnostic workups in single visits • Reducing admission rates to inpatient services • Limiting need for interhospital transfers • Allowing coordination of care by other specialists for patients with multiple medical problems

6. Benefits of E.M. to the General Public • Reassurance and confidence • Convenience • Ensured access to care • Education • Illness & injury prevention • Correct utilization of health care system • Appropriate followup care

7. 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

8. 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

9. 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

10. Unique Subjects to Teach Students and Residents in the E.D. • Cost-effective ancillary test ordering • Efficiency in patient flow • Managing multiple simultaneous patients • Coordinating prehospital and E.D. care • Focused approach to medical problems

11. Minimum Basic Subjects to Teach Medical Students & Residents in the E.D. • Recognition of emergencies • Airway management • CPR • Focused evaluation of : • Headache • Chest pain • Dyspnea • Abdominal pain • Fever • Suturing / wound care

12. 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 topics • Extracurricular "workshops" or "labs" : • Suture technique • Airway management • Blood drawing • Intravenous line placement • Splint & cast application • EKG interpretation • X-ray interpretation

13. 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

14. 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

15. General Structure of U.S. E.M. Residency Programs • 75 % of programs are PGY 1,2,3 • 15 % of programs are PGY 2,3,4 • Require "rotating" or "transitional" internship first • 10 % of programs are PGY 1,2,3,4 • A 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

16. 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

17. Non-E.D. E.M. Rotations Usually Included in E.M. Residency Programs • Toxicology • Pre-hospital care • Aeromedical care (flying usually optional for residents) • Research • 1 to 2 months of electives

18. Career Options for E.M. Residents Graduating from U.S. Programs • Private 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 training • Locum tenens work

19. U.S. E.M. Fellowship Training Programs (following E.M. residency) • Emergency Medical Services (Prehospital care) : 1 to 2 years • Toxicology : 2 years (separate subspecialty certification) • Pediatric E.M. : 2 years • E.M. Research : 1 to 2 years • E.M. Administration : 1 year • E.M. Education : 1 year • Hyperbaric Medicine : 1 year • Sports Medicine : 1 to 2 years • Critical Care (Intensive Care) Medicine : 1 to 2 years • Aeromedical Care : 1 year • International E.M. : 1 to 2 years (may include obtaining an M.P.H. degree)

20. Facility Requirements for U.S. E.M. Residency Programs • Patient census > 30,000 (total) per year • Pediatric census 15 % or 4 months full time equivalent • Critically ill / injured patients : at least 4 % of census or > 1000 per year • At least 2000 patient encounters per resident per year • Accredited medicine & surgery residencies must be at same clinical site • Must have offices for faculty & residents • Stat lab results should be available in < 1 hour • Must have at least 5 hours per week didactic instruction by faculty

21. 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 week • Must have at least one day off in every 7 days • Must 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 logbook • Must have followup information on admitted patients • May not be supervised by resident physicians from specialties other than E.M. when in the E.D.

22. 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

23. 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 specialty • Independent specialty board exam : the American Board of Emergency Medicine (ABEM) • Subspecialty certification (pediatric E.M., toxicology, sports medicine) • Independent Residency Review Committee • Popular as career choice among medical students • Popular with the public (thanks to TV) • Extensive current research efforts

24. 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 members • 4750 E.D.'s

25. 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

26. 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"

27. Legislative Efforts by E.M. on Behalf of the Public • "Prudent layperson" laws to ensure access to care • Support for prehospital care systems • Injury prevention • Violence control • Measures to limit driving while intoxicated • Public education

28. 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

29. Social - Societal Problems in the U.S. Which Result in Increased Need for E.M. • Tobacco smoking • Alcohol abuse • Driving while intoxicated • Most common cause of serious vehicle accidents • Violence / assaults • Obesity • Lack of health insurance • Child and elder neglect

30. 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

31. 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 journal • Monthly newsletter • Has 29 different committees, task forces, & interest groups (International is largest one) • > 500 research abstracts at annual meeting

32. 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

33. Some of the Research Areas in Which E.M. Researchers Play a Leading Role • Fluid resuscitation • CPR • ACLS • Asthma • Injury prevention • Pain management • Disaster management

34. 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

35. E.M. Non-Peer Reviewed Journals • Emergency Medicine News • Journal of Emergency Medical Services • Emergency Medical Services • Air Medical Journal • Journal of Air Medical Transport • Emergency Medicine

36. 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