The Role of Emergency Medicine in the Future of American Medical Care
Executive Summary from "The Role of Emergency Medicine in the Future of American Medical Care," Josiah Macy Jr Foundation, April, 1994.
The following recommendations, endorsed by 32 of the participants, represent the Planning Committee's summary of general discussions at the conference:
1. The United States Public Health Service in its next "Statement of Public Health Objectives for the Nation," should specify, as a new goal, that access to high quality emergency medical care should be available for all persons who need such care.
At present, high quality emergency medical care is not universally available to the U.S. public. Furthermore, the lack of such care is not adequately addressed in the current U.S. Public Health Service statement of the nation's health care goals. Access is particularly lacking in many rural areas, but acceptable quality emergency care may be absent as well in many urban and suburban areas.
2. Federal, state, and local governmental organizations, including the Council on Graduate Medical Education (COGME), should ensure that the number of residency positions in Emergency Medicine is not reduced as planning for health care reform proceeds.
Emergency Medicine physicians are critically important medical specialists whom many consider to be in short supply at the present time. In many communities Emergency Medicine physicians not only provide emergency care, but also are the only providers of much primary care to patients for whom access to generalist physicians is difficult or impossible.
Since the demand for Emergency Medicine physicians will be greatly affected by health care reform, the work force needs of the specialty are difficult to predict. Therefore, there should be no arbitrary change and, in particular, no reduction in the current number of residency positions in Emergency Medicine, unless the impact of such change has been studied and justified within a reformed health care system.
3.The Society for Academic Emergency Medicine (SAEM), the American College of Emergency Physicians (ACEP), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) should revise the classification of emergency departments. This classification should reflect the level of care available for emergency patients, and indicate whether or not the facilities are adequate and whether appropriately qualified and credentialed emergency physicians are available 24 hours a day. In addition, this classification of emergency departments should establish minimum qualifications for physicians, nurses, and other health professionals who provide services in emergency departments, with special attention to the qualifications of "moonlighters."
Currently, the United States has an inadequate system to classify emergency departments. As a result, it is impossible for the public to know what level of care an emergency department is capable of providing. In the interest of both protecting and informing the public, a classification system for emergency departments should be developed that is comparable to the one that classifies each hospital- based trauma center on the basis of the level of sophistication of care it provides.
Such a classification of emergency departments should particularly reflect the qualifications of physicians who staff each emergency department. The presence of physicians in emergency departments who are neither adequately nor appropriately trained is not conducive to high quality emergency care. Yet, many emergency departments continue to be staffed with physicians in specialties other than Emergency Medicine or with residents in training or with physicians who have as little as one year of graduate medical education. The classification of emergency departments must especially address the qualifications of "moonlighting" physicians, most of whom provide no emergency care in their primary positions and work additional hours part-time in emergency departments without specialty training in Emergency Medicine. In addition, many "moonlighters" lack training and adequate experience in any aspect of primary health care.
The classification system should serve as a challenge and a guide to emergency departments as they work to improve their facilities and services. Since emergency departments in rural areas may not be staffed with Emergency Medicine specialists, these emergency departments cannot be expected to conform to a high level classification. Nevertheless, physicians practicing in these settings must be trained to provide the highest level of care possible, and should meet standards set by the specialty.
Rural communities should be assisted in developing rapid transportation and communication systems that provide links between their emergency departments and academic health centers and other high level emergency care providers to ensure expedited professional consultations, patient referrals, and continuing professional education.
4.State medical licensing boards, the National Board of Medical Examiners, the Liaison Committee on Medical Education (LCME), and medical school deans and faculties must ensure that every medical student has acquired the appropriate knowledge and skills to care for emergency patients. This education must be provided through educational experiences supervised by appropriately qualified emergency physicians.
Contrary to the public's expectations, few U.S. medical schools adequately train their students in the fundamentals of emergency care and life support. Less than 20 percent of U.S. medical schools have required courses in Emergency Medicine in their curricula.
To correct this deficiency, the medical licensing boards of each state should require applicants for medical licensure to have had specific training in emergency care during medical school. Also, the United States Medical Licensing Examination should specifically test students' competence in this subject.
Although faculty members from many different medical specialties may contribute to instruction in emergency medical care, physicians certified in Emergency Medicine are best qualified to be teachers of emergency care. In addition, specialists in Emergency Medicine can contribute importantly to other subjects in the medical school curriculum and should be active participants on curriculum committees.
Medical students, as part of their training, should learn about the clinical and economic constraints of care in emergency departments. They should also understand the ethics of emergency care and the responsibility emergency departments bears as a "safety net of last resort" for individuals who have no other source of health care.
5.The deans and faculty of all LCME-accredited medical schools, with the assistance of the Association of American Medical Colleges and the Association of Academic Health Centers, should establish in their schools appropriately staffed and supported academic departments of Emergency Medicine.
Recent surveys show that less than 50 percent of U.S. medical schools have academic departments or autonomous divisions of Emergency Medicine. By creating academic departments of Emergency Medicine, medical schools can best establish and implement high standards for educational programs in emergency care, and strengthen collaborative professional relationships necessary for research and for high quality clinical services in emergency care. Departments of Emergency Medicine must be large enough and receive adequate support in order to develop and nurture faculty role models and mentors.
The Residency Review Committee in Emergency Medicine should reevaluate its requirements for establishing training programs. These requirements now seriously constrain some medical schools from developing new departments with residency training programs.
Additional training programs and residency positions in Emergency Medicine should be especially encouraged at medical schools that are establishing new academic departments.
Faculty and trainees in Emergency Medicine must be responsible for enhancing their level of scholarship to gain academic recognition and to warrant designation as an academic department.
6.The American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) should quickly convene a conference to develop an agenda for research in Emergency Medicine and to define strategic options for implementing that agenda.
The discipline of Emergency Medicine currently lacks a broadly accepted and defined research agenda. This deficiency impedes its continued development as a clinical field and its fulfillment as an academic medical specialty. Emergency Medicine offers a broad spectrum of research opportunities -- in basic medical sciences and in health services research. To explore opportunities for collaborative research, the proposed conference should include representatives of other health professions organizations.