V. Gail Ray, MD
Richard C. Lotsch, DO
The specialty of emergency medicine (EM) embodies the belief by those who have chosen it as a career that "quality emergency care is a fundamental individual right and should be available to all who seek it." Further, "there is a body of knowledge unique to emergency medicine . . ." and it "is best practiced by qualified, credentialed emergency physicians."1 Today there are more than 30,000 practicing emergency physicians with over 14,500 certified by the American Board of Emergency Medicine. With approximately 100 million annual emergency department visits in over 4900 hospitals, it is easy to calculate the severe shortage of qualified emergency physicians. Current projections are that this shortage will extend at least for the next 2-3 decades.2,3 Since EM is one of the newest and most underserved specialties, there are ample opportunities for the new physician who wants to enter this challenging and rapidly evolving branch of medicine.
Emergency medicine is a relatively new specialty which has evolved just over the last quarter of a century. For many years, hospitals provided emergency care merely as an obligation, seeing no profit or marketing through goodwill. In the 1960's, such care consisted of an "emergency room" operated by the nursing supervisor who might dispense care and medications via physician telephone orders or, if in her opinion of an extreme case, call in an unwilling junior house officer or physician at home. The equipment was usually passed down from other services. Worst of all, accident victims received no prehospital care and were often transported to the hospital in the undertaker's hearse.
The American College of Surgeons was among the first groups of physicians to recognize the need for organized emergency services. The A.C.S. published progressive recommendations, but no specialties were willing or able to take on the project as the concept didn't fit within the scope of any established specialty. As patient demand increased, more physicians began to staff emergency departments on their own. In 1968, this budding young group of emergency physicians joined together to found the American College of Emergency Physicians. In 1970, the first emergency medicine residency was started at the University of Cincinnati and a host of other residency programs were soon to follow. ACEP worked hard during the seventies to achieve specialty status for these new residency graduates. A core content of knowledge and skills for EM was established; a specialty journal, now known as the Annals of Emergency Medicine was founded; textbooks were written; an interim Residency Review Committee was initiated; and continuing medical education courses were offered. All the necessary factors were in place when in 1979, emergency medicine was recognized as medicine's newest specialty by the American Board of Medical Specialties.
In 1980, the first certifying examination was administered by the American Board of Emergency Medicine. Initially, ABEM outlined two different tracks a physician could follow to become qualified to take the certifying examination in emergency medicine: (1) Graduation from a residency program approved by the Residency Review Committee, or (2) A practice track was also created as an interim method of "grandfathering" in qualified physicians who had no opportunity to formally train in emergency medicine and who had significant experience in emergency medicine practice. This track expired in June 1988. ABEM strives to maintain the highest qualifying standards by requiring recertification every ten years.
Utilization of emergency services has steadily grown throughout this time span, showing an increase of 45.9% from 1973 to 1994. The public has become aware of EM as a specialty entity and consumer expectation is certainly reflective in this increase in utilization. It is only appropriate that the physician who manages the most life-threatening situations be the best trained and qualified.
The emergency physician's (EP) chief duty is to stabilize emergent patients and to see that all life-threatening causes of illness are thoroughly worked up and ruled out, when possible. If not possible, the EP must see that the patient is admitted to the most appropriate service to further explore the problem. This presents quite a dilemma to the EP who usually has no admitting privileges, will not be ultimately responsible for continuing care and must rely upon the consultant to carry out a plan of action. It places the EP in the unique position of becoming the patient's advocate. The EP must also rely heavily upon an innate ability to single out the sick patients from the undifferentiated masses of those presenting because such patients might otherwise be overlooked in a busy department where so many others are demanding attention. It becomes the EP's job then to quickly recognize the sick, stabilize them in the absence of complete information and efficaciously work them up to reach a tentative diagnosis in the shortest time possible. All of this requires a quick mind, a decisive nature, a good fund of knowledge and interest in the breadth of medicine, excellent physical diagnostic skills, good manual dexterity, the deductive ability of a detective, and nerves of steel. It is also necessary to have special communication skills as the need frequently arises to establish rapport in a very short time with people under very stressful conditions. The EP must have an attitude of cooperation as success in practice depends upon working effectively as a team member.
Any student contemplating a career in EM should be willing to accept the limitations of the specialty. Most notably, at least 50 percent of all patient visits will not be emergencies. These may be patients seeking minor episodic care, second opinions, and possibly even emotional or socioeconomic support. The EP must tend to these multiple patients while simultaneously caring for the truly emergent. It becomes necessary to prioritize and often defer definitive diagnoses and treatment to more appropriate settings. Many patients with financial or personal problems present because they have no alternate source of medical care. The EP cannot select patients but must see even the most abusive. Frequently, it becomes a thankless job and the EP must rely upon intrinsic reward systems to self-renew. If the EP doesn't truly enjoy the milieu of a busy, erratic department, and the fascination of being the first to diagnose the sick patient, the negative aspects will soon overshadow the rest. Other factors to consider are related to the physical demands. Usually, the EP works alone as the only physician on duty unless the census of the department justifies more coverage. Even so, the work is physically demanding with intense work shifts, sometimes 12 hours and often without time to sit down or take meal breaks. This work pace often excludes women in the third trimester of pregnancy. In addition, the work shifts covering 24 hours in a day will vary throughout the month, constantly disrupting circadian rhythm. So while the work schedule is predictable and flexible, it is by no means "regular." The EP will routinely work rotating weekends and holidays thereby being excluded from occasional social and family affairs. To avoid career mistakes or burnout down the line, the student should have realistic expectations. An elective in EM will help to determine if the student really enjoys the milieu of the department. Personality inventories such as the Myer-Briggs Test administered by student affairs offices are helpful to determine if personality characteristics are suited to the lifestyle and practice. Not all medical schools yet have emergency departments staffed full-time by appropriately qualified emergency physicians. Therefore, it may be difficult for many students to examine first-hand the realities of practicing emergency medicine or even get realistic career advice regarding the specialty. (The professional organizations listed in the footnotes have dedicated themselves to providing this needed service).
Residency training in EM is strongly advised for any candidate considering a career in the field. Many students in the past have been advised to train in a "traditional" specialty and then cross over to the field, but since the practice track for board certification no longer exists, diplomate status ("board certification") in emergency medicine will not be possible without completing an emergency medicine residency . Also, as more and more residency trained EP's enter the job market, it is unlikely that physicians trained in another specialty will be competitive for jobs in emergency medicine. The best reason of all to train in emergency medicine, however, is to become both competent and confident in caring for all the patients who come to the emergency department seeking emergency care. Residency training programs in EM may vary in both length and the graduate year to training. Most programs are three years and begin with the first postgraduate year. There are a few four year programs and several more three year programs which start at the second postgraduate year. All of the programs must meet the high standards set by the Residency Review Committee. The first postgraduate year usually consists of rotations covering all the major services with two to three months on the emergency service. The latter two years are weighted toward the emergency service with the addition of critical care, trauma, and administrative rotations. Where available, the fourth year usually entails more specialized rotations to learn the intricacies of toxicology, prehospital care, research and administration. There are also available many one year fellowships devoted to these areas. This stairstep kind of arrangement allows the resident to develop a broadbased background and build upon it steadily in the emergency arena where the nuances of the practice will differ from the primary services.
Competition for a residency slot in emergency medicine ranks close to the top for all specialties.5 Presently, there are more than 125 EM residency programs which fill approximately 1,030 entry-level (RRC-approved) positions annually through the NRMP Match. In 1997, the fill rate for these RRC-approved residency positions in the US was 97.8% with 77.4% of the positions filled with US graduates.6 A range of six to ten applicants per residency slot have competed since 1983. For osteopathic medical students, there are an additional 95 residency positions in 26 EM residency programs approved by the American Osteopathic Association whose graduates are eligible for board certification by the American Board of Osteopathic Emergency Medicine.3
To be competitive for a residency position in EM, the student should have a record of solid academic performance with good letters of support for clinical ability. Most residency programs will screen applicants for these qualities and establish upon interview the applicant's personal qualities needed to succeed in this field. Any evidence the candidate can provide regarding a realistic understanding of and commitment to the specialty will virtually guarantee a residency position to the student with basic qualifications. Usually, an outside elective in emergency medicine will help to state the candidate's case in addition to providing further letters of recommendation. Should the applicant fail to secure a residency position, the best bet is to seek expert advice from his or her medical college dean as recent changes in government funding of graduate medical education may adversely impact those who pursue a transitional year prior to entering a residency in emergency medicine.
Emergency physicians treat patients of all ages and both genders with medical problems covering the breadth of medicine. They deal with episodic and emergent care, leaving the followup of chronic problems to others. Much of the care is routine, but the variety and pace are totally unpredictable, an aspect many EP's enjoy. The negative aspects include the loss of positive feedback from patients, little followup information, and the predictable flow of abusive patients. The lack of regular hours takes its physical toll, offsetting the benefits of a flexible and predictable work schedule. Since EM is relatively young, few statistics about the practice and practitioners has been collected yet. Approximately 16 percent of ACEP members are minorities and 18% women, but it is expected that many more are practicing part-time. Minorities and women were, however, 20 and 26 percent respectively, of resident graduates in 1995. Generally, minorities and women are well- accepted in this specialty, which tends to have the ideals and standards of a younger society. However, one of the problems for EM as a whole has been the fact that many physicians are on the average an older generation who still remember the "emergency room" of a few years back. Winning the respect of these colleagues has been difficult as they tend to cling to established practice habits. But as more and more physicians are educated in the presence of EM programs or through their practice learn to rely upon the qualified EP for care of their patients, this image will gradually dissolve. Practice styles will vary as widely as the settings in which they are located. The majority are practiced in the community setting where a broad spectrum of patient encounters will range from minor colds to poisonings, rapes, automobile crash injuries, spouse and child abuse and heart attacks. ED's in inter-city hospitals provide care for a large segment of indigent and otherwise uncared for patients who often present in extremis. They also see a great deal of traumatic injuries, especially weapon-inflicted. In the smaller, rural hospital, the ED may serve as the only resource for primary care in the community.
There is currently a shortage of board-certified emergency physicians which is expected to last well into the next century.2,3,4 In a recent survey, there were over 30% more positions than the number of EM residents graduating annually.4 As one might expect, graduating EM residents have very little difficulty securing employment. The salaries and benefits depend upon the setting and the type of practice. In 1995, however, entry level positions in community practice generally averaged $150,000 annually, plus benefits. An established EP will earn around $200,000 and in exceptional cases earnings may exceed $300,000 annually. Almost all positions will offer some basic benefits, including paid malpractice insurance premiums. The types of reimbursement will range from salaried hospital employee to independent contractor. Most community settings will have fee for service arrangements and opportunity for partnership. There are also salaried positions with health maintenance organizations and academic institutions. The cost of setting up practice and overhead are low so that new residency graduates can begin earning competitive incomes immediately. In addition, women considering childbearing and rearing and men who want to devote more time to family have great flexibility in choosing from a variety of practice styles and can still earn good salaries.
An EP will usually work 45 to 60 hours a week but there is ample opportunity for part-time work. Besides clinical duties, an EP must work closely with hospital administration, medical staff and committees to build and maintain efficient emergency services. Equally important, a close working relationship with nursing and ancillary personnel must be fostered to provide the teamwork necessary in an emergent situation. Additionally, the EP must reach out into the community to establish and provide services for prehospital care and disaster planning. Community service will include teaching prevention and awareness, as well as bystander readiness to deal with cardiac arrest and other acute situations. If emergency medicine is an underserved specialty, then academics in this branch is even more so. There are over 50 academic centers with a department of emergency medicine. There is a short supply and heavy demand for faculty to staff these departments and the residency programs. With the firm establishment of the specialty, many more medical schools are expecting to staff their teaching programs with qualified faculty and eventually to initiate residency programs. The future of the specialty depends upon its ability to supply these individuals who can establish a strong research base and train the clinicians of the future. The field is wide open and the aggressive physician can advance rapidly. Unfortunately, the salary for academics, similar to other specialties, falls short of the private practice potential, but the benefits and intrinsic rewards are great. Research in this specialty can be as varied as the medical problems that present. Emergency physicians tend toward clinical research, as this is what usually attracts the physician to the specialty. But there is a growing segment of basic science researchers as well as many whose interests involve public health and administrative needs. Three particular areas of wide interest for EP's are cerebral-cardiopulmonary resuscitation, injury prevention, and clinical outcomes.
With only a short past to reflect upon, one might be hesitant to predict the future for emergency medicine. The recent acceleration in the pace of change in health reform should cause anyone entering the field to carefully consider how the specialty will fit into the spectrum of health care providers. However, when one considers the energy and enthusiasm that emergency physicians have typically shown in meeting their challenges, optimism must prevail. Emergency medicine, as a newcomer, has been the bell-weather for medicine in general. It has been the testing ground for the impact of the changing social conditions and governmental responses in our country. And, thus far, EM has been a leader for innovation and positive change in meeting the crises facing medicine this past decade. The RRC for EM has been active in promulgating high standards for residency training including issues such as limiting resident work hours, structuring curriculums and providing appropriate full-time and on-site resident supervision. Opportunities to subspecialize exist in the areas of pediatric emergency medicine, medical toxicology and sports medicine. The American Board of Emergency Medicine is currently working on developing subspecialty certification for critical care medicine. There are fellowships to study in these areas as well as in aeromedicine, hyperbaric medicine, administration,prehospital care, and looking ahead, possibly observation medicine. These latter areas provide additional competence but pathways do not currently exist for board certification. There is dual board certification in emergency medicine with internal medicine. As the majority of EP's grow older together, there will be increased emphasis on creating a specialty more accommodating toward healthy lifestyles. Increasing numbers of younger physicians and women will play a vital role toward overcoming the specialty's attrition rate due to stress and job dissatisfaction as they introduce needed ideas to balance work with family, health and personal happiness. Increasingly, the ED is viewed as a marketing tool by hospital administrators, even though it is not often a revenue producer. To maximize this asset we will have to find ways of meeting the increased public awareness and expectation of utilizing the ED primarily for convenience factors. Expansion of emergency services to include intensive diagnostic, treatment and observation units, and "fast track" or urgicare centers may become commonplace.
Emergency medicine developed as a specialty by meeting the immediate needs of a vast and varied patient population unserved by other physicians largely due to the nature and timing of those medical needs. Just so, it remains largely speculative as to how emergency medicine will continue to evolve and grow to meet the changing medical needs in a rapidly changing society. But one thing is for sure: this specialty is comprised of one of the youngest and most dedicated groups of physicians who have become accustomed to pioneering new ideas and blazing the path for other specialties more traditional and less flexible to reluctantly follow in. The future looks bright indeed for this growing specialty and for those who take on the challenge of becoming the next generation of emergency physicians!
Dr. Ray graduated from the University of Arkansas College of Medicine where she is now Professor and Chairman, Department of Emergency Medicine. She completed her emergency medicine residency at Truman Medical Center, University of Missouri in Kansas City, just as emergency medicine was declared a specialty and was among the first Diplomates of the American Board of Emergency Medicine as well as the first group to recertify. She helped to found the emergency medicine residency program at Texas Tech in El Paso and served as Residency Director for Emergency Medicine at East Carolina University School of Medicine in Greenville, NC.
Dr. Lotsch graduated from Philadelphia College of Osteopathic Medicine and is currently a resident in emergency medicine at Albert Einstein Medical Center in Philadelphia, PA.
Residency programs, student rotations and faculty advisors, Contact: Society for Academic Emergency Medicine 901 N. Washington Avenue Lansing, MI 48906 (517)485-5484, FAX (517) 485-0801, firstname.lastname@example.org
American Academy of Emergency Medicine, www.aaem.org
American Board of Emergency Medicine, www.abem.org
American College of Emergency Physicians, www.acep.org
American College of Osteopathic Emergency Physicians, www.acoep.org
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