Status of Academic Emergency Medicine in the U.S.A. Jim Holliman, M.D., F.A.C.E.P. Professor of...
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Transcript of Status of Academic Emergency Medicine in the U.S.A. Jim Holliman, M.D., F.A.C.E.P. Professor of...
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