Emergency Medicine: Coming Of Age

David J. Vukich, M.D.
David J. Vukich, M.D. is Associate Professor and Interim Chairman, Department of
Emergency Medicine at the University of Florida Health Science Center / Jacksonville.

The "new" specialty of Emergency Medicine is already about thirty years old and slowly earning its place among the other disciplines. And, even though it is the only specialty to have its own top-rated national television show it is still somewhat unknown or misunderstood by some of our colleagues as well as the lay public. Emergency Medicine is indeed quite unique and it has undergone a very different evolution than most specialties. If for no other reason, this occurred as a consequence of being developed in the last few decades of this century with its high-tech and tumultuous healthcare environment. It is still a very young specialty with the average practitioner being under 40 years old. Most of the physicians who have ever become board certified in emergency medicine are still in practice! The core of the specialty involves a relatively constant service of emergency, urgent and primary care but emergency medicine has proven itself enough to adapt continuously with new responses to healthcare needs.

National History

The actual beginnings of the specialty emerged in the late 1950's and 1960's with the realization that lessons learned in the Korean and Viet Nam conflicts could be applied on the "home front". Techniques and procedures that were developed for the battlefield could also save thousands of Americans every year. The need for timely triage and beginning treatment in the first crucial minute of an injury or illness was recognized. But as recently as the 1960's emergency care in the United States was at best inconsistent. Inadequately equipped emergency "rooms," staffed only by nurses, provided much of the care. Interns or "on call physicians" -- physicians from other specialties required to "pull ER duty" to maintain their hospital privileges -- were called in as needed.

Even as late as the mid-1960's many U.S. hospitals didn't have emergency departments and most prehospital transport was still being provided in hearses, the only vehicles large enough to allow the supine position! But as medical advances and diagnostic equipment improved there came a huge demand for increased access to care. From 1954 to 1964 the number of emergency visits nearly tripled. This placed a great deal of attention on emergency services and in 1966 the National Academy of Sciences published its landmark report, Accidental Death and Disability, The Neglected Disease of Modern Society. This alarming story pointed out the incredible deficiencies of emergency care and it quickly led to a mandate from patients and physicians to improve the American emergency care system.

During this time it also became apparent that emergency care required uniquely different skills and training from general medical practices. Some groups of physicians began experimenting with staffing patterns, certain specialties from the medical staff and 24 hour coverage for the emergency department. Significant advances were made but there were still no training or recruitment opportunities for young doctors interested in emergency medicine. Finally, in 1968 a group of eight physicians formed the American College of Emergency Physicians (ACEP) the goal of which was to provide quality emergency care by education, structure and standards for the new "emergency physicians." Fueled by increasing demand from "consumers" and a growing popularity among physicians, this was the beginning of incredibly rapid growth for the specialty.

By 1969 they held their first Scientific Assembly in Denver, Colorado with 128 physicians attending and one year later the first emergency medicine residency was started at the University of Cincinnati. In 1972 the premier issue of the Annals of Emergency Medicine was published. By 1973 the AMA allowed a provisional seat for ACEP on the AMA House of Delegates and this was made permanent in 1975. In 1976 the American Board of Emergency Medicine (ABEM) was formed and four years later the first board certified emergency physicians in history received their credentials. Today ABEM has earned primary medical specialty status with the American Board of Medical Specialties and physician membership in ACEP will require board certification or board eligibility after the year 2000. Continuous board certification requires re-examination every ten years.

Local Emergency Medicine History

Jacksonville was not significantly different than other areas of the country in the 1950's, but it did benefit from two extraordinary occurrences by the 1970's. The first enhancement of emergency services was the work of a new cardiologist in town who had a great interest in emergency cardiac care. Prior to the existence of emergency physicians Dr. Roy Baker became devoted to the improvement of pre-hospital and emergency services and he envisioned a flawless continuum of care from the field to modern emergency departments (ED's). Due to his efforts and those of other visionaries in the Jacksonville Fire Department a multi-million dollar federal demonstration grant for EMS systems was won for the Jacksonville area. Prehospital care soon saw its first paramedics and legitimate ambulances on the streets of Jacksonville. The high quality of the service and demand from citizens soon made rescue services a standard part of city government which remains today. Also in the 1970's a new residency in emergency medicine was started at what was then the University Hospital of Jacksonville. This was a somewhat courageous act, to invest in a new and untried specialty but the service commitment of the "city hospital" was daunting and the emergency department was described as a "war zone". At one point the ED was treating over 125,000 patients per year. Structure, training and quality were desperately needed.

Dr. John Farquhar was named as the first chief and residency director and the inaugural class of residents began in 1975. These first emergency physicians graduated from the "University" program in 1977 (see Figure 1). Since then, hair styles and healthcare have changed immeasurably and the emergency medicine residency and practice has kept pace. Many faculty members, residency directors and chairpersons contributed their efforts over the past 24 years and the result has been a nationally recognized training program. Graduates from this program as well as from other residencies began practice in Jacksonville area hospitals, and the quality of emergency service escalated rapidly. Meanwhile at University Medical Center, emergency medicine joined with the other specialties as the "arms length" affiliation with the University of Florida became a direct link in 1988 and all faculty became appointed professors with the university.

Figure 1. (from left to right) Carmen Haynes, M.D., Rod Copeland, M.D., Bob Springer, D.O., John Stimler, D.O., Mark Tafflin, D.O., and Art Sidransky, M.D.

Current Status Of Emergency Medicine

The emergency departments of our local hospitals are now recognized as critical to the operation of the institutions and the emergency physicians are involved intimately in medical staff affairs. Jacksonville has spawned a number of state and national leaders from its emergency physician ranks and it is easy to attest that the overall quality of emergency care in our city is exceptional.

Academics

Many of the area emergency physicians routinely provide local, state and national education efforts. Additionally, a number of local emergency physicians have been board examiners or faculty members in this or other training programs. The original site of the Jacksonville EM training program, University Medical Center, and the medical education consortium of the 1980's, the Jacksonville Health Education Program (JHEP), have spun off into the University of Florida Health Science Center / Jacksonville. This is still the location of the EM training program but the first class with six residents (Figure 1.) and two faculty has now grown to 43 residents, three fellows and 20 full-time faculty. Graduates are recognized as some of the best trained in the country and many of this areas' practicing emergency physicians are alumni or part-time faculty. The program produced 22 scientific publications last year alone and has graduated over 300 residents since 1977. Nationally there are now 120 emergency medicine training programs graduating approximately 1,000 residents per year.¹

Perhaps the greatest academic accomplishment for this training program came only 5 months ago when Dr. Ken Berns, Dean of the College of Medicine, University of Florida, announced that emergency medicine would be elevated to full department status within the medical school. And, in a reversal of the usual structure, the chair and the "headquarters" of the department will be located in Jacksonville rather than Gainesville. This is a "first" for the University and a credit to emergency medicine in our entire city. The University of Florida is now the 56^th medical school of 125 in the U.S. to establish a formal department of emergency medicine (See Table 1).

Table 1. Academic Departments of Emergency Medicine
Academic Institution	Year Achieved Departmental Status	Academic Institution	Year Achieved Departmental Status
University of Southern California University of Missouri-Kansas City University of Louisville East Carolina University Wright State University University of Kentucky George Washington University Loma Linda University Allegheny Univ. of Health Sciences, Philadelphia University of Cincinnati Uniformed Health Sciences University Albany Medical Center Northeastern Ohio Universities Georgetown University Bowman Gray School of Medicine State University of New York, Buffalo Texas Tech University Ohio State University State University of New York, Stony Brook Wayne State University State University of New York, Brooklyn State University of New York, Syracuse University of New Mexico University of North Carolina, Chapel Hill Eastern Virginia Medical School Medical College of Wisconsin Oregon Health Sciences University Texas A & M University	1971 1972 1974 1980 1980 1983 1984 1984 1984 1984 1985 1986 1986 1988 1989 1989 1989 1990 1990 1990 1991 1991 1991 1991 1992 1992 1992 1992	University of South Alabama New York Medical College University of Pennsylvania University of Rochester University of Texas, Houston West Virginia University Johns Hopkins University Mount Sinai Medical Center Tufts University University of Arkansas University of Massachusetts Finch University/Chicago Medical School Albert Einstein College of Medicine University of Alabama University of Mississippi University of Pittsburgh University of Virginia Vanderbilt University Boston University Louisiana State University, Shreveport Rush University Medical College of Virginia Medical College of Georgia Emory University Allegheny Univ. Of Health Sciences, Pittsburgh Robert Wood Johnson Medical School University of Connecticut University of Florida	1993 1993 1993 1993 1993 1993 1994 1994 1994 1994 1994 1994 1995 1995 1995 1995 1995 1995 1996 1996 1996 1996 1996 1996 1997 1997 1997 1999

Scope Of Practice

Certainly the core practice of emergency medicine is not unfamiliar but the diversity of practice and the range of involvement are unusually broad. Emergency physicians routinely provide emergent, urgent and primary care. But, some of the other avenues now include hyperbarics, toxicology, occupational health and pediatric emergency medicine. Cost saving "products" developed as a response to managed care and federal budget cutbacks include ED observation units (OBU) for 12-23 hours stays and chest pain or rapid decision making units (RDU). These units allow diagnosis and treatment that was once in-patient based to be performed at a fraction of the overall cost as an ED outpatient. Some ED groups are also beginning to provide hospitalists or in-patient services when there is support and need from the medical staff. While in-patient critical care services were once thought to be a "natural" for emergency physicians, this has not been an area frequently developed or utilized.

Emergency Physician Manpower Needs

Training in emergency medicine has become very popular and the specialty ranks behind only three others for career choice by graduating medical students.²Currently our program anticipates 600 resident applications for 15 first year positions. Of the 31 medical specialties, graduating emergency medicine residents rank third behind orthopedics and critical care/pulmonary as most likely to find immediate employment after graduation.³Despite the 120 residency programs in the United States there are only three in Florida and a manpower shortage still exists for the specialty. The rate of emergency physicians leaving practice or retiring is nearly equal to the supply of graduating residents so the shortage is not likely to resolve soon.

Of the approximately 2,000 physicians practicing emergency medicine in the state of Florida, only 729 (36%) are board certified.⁴ Nationally 54% of emergency physicians are board certified although this number is increasing each year.⁵ Clearly additional training is needed.

Financial Impact Of Emergency Medicine

Emergency services account for only 3% of the entire healthcare budget but the "downstream" impact of this is far greater. ED's are now one of the primary sources of admissions to hospitals. In one case (UFHSCJ), up to 60% of all hospital admissions begin as emergency department patients. The impact of ancillaries is also substantial as x-ray, lab and other services are frequently involved. In addition, the emergency department has become one of the constant battlefields for managed care organizations. At times, extreme measures have been taken by some of these firms to reduce ED usage by their insured populations. Earmarked initially as the site for gatekeeping, this role has been modified extensively over the past few years in an effort to protect patients and maintain the financial viability of ED's. Lastly, the extensive cost shifting utilized in order to provide the very expensive but under-reimbursed critical care in the ED's has given the reputation of expensive primary care to emergency medicine. While an analysis is too lengthy for this article, there is ample evidence that while the charge for primary care in the ED is high, the marginal cost to provide it is very close to the cost of a primary care office visit. This may have impact as health systems make efforts to capture the high fixed costs of ED's by directing more primary care to these sites, particularly during times of underutilization.

Summary

Emergency Medicine has developed rapidly since its inception 30 years ago. It is deeply involved in the American healthcare system and it plays a pivotal role in may current issues. In Jacksonville, the specialty has benefited from involved and progressive emergency physicians in the community as well from the University of Florida training program. Emergency medicine is a flexible and progressive medical specialty that no doubt will continue to evolve.

References

Hoffman GL, Bock BF, Gallagher EJ, Markovchick VJ, Ham HP, Munger BS. Report of the Task Force on Residency Training Information, American Board of Emergency Medicine. Annals of Emergency Medicine. 1998; 31:5; 608-625.
Barzansky B, Jonas HS, Eltzel SI. Educational programs in U.S. medical schools, 1997-1998. JAMA. 1998; 280: 803-808.
Miller RS, Dunn MR, Richter TH, Whitcomb ME. Employment seeking experiences of employment seeking residents during 1996. JAMA. 1998; 280: 777-783.
Florida College of Emergency Physicians. Demographic Data, 1998.
Moorhead JC, Gallery ME, Mannie T, et al. A Study of Workforce in Emergency Medicine. Annals of Emergency Medicine. 1998; 31:5; 595-607.

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