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.
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 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
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
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 ordering
Efficiency in patient flow
Managing multiple simultaneous patients
Coordinating prehospital and E.D. care
Focused approach to medical problems
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
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
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 1,2,3
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
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
Toxicology
Pre-hospital care
Aeromedical care (flying usually optional
for residents)
Research
1 to 2 months of electives
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
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)
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
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.
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 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
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
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 systems
Injury prevention
Violence control
Measures to limit driving while intoxicated
Public 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 smoking
Alcohol abuse
–Driving while intoxicated
–Most common cause of serious vehicle accidents
–Violence / assaults
Obesity
Lack of health insurance
Child 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 journal
Monthly newsletter
Has 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 resuscitation
CPR
ACLS
Asthma
Injury prevention
Pain management
Disaster 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 News
Journal of Emergency Medical Services
Emergency Medical Services
Air Medical Journal
Journal of Air Medical Transport
Emergency 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