CONCEPTS
academic emergency medicine
T e Place of EmergencyMedicinein the Academic Community From the Association of Arrverican Medical Colleges, Washington, DC.
Robert G Petersdorf, MD
[Petersdorf RG: The place of emergency medicine in the academic community. Ann Emerg Med February 1992;21:193-200.]
Adapted from the Robert H Kennedy Lecture at the Societyfor Academic Emergency Medicine Annual Meeting in Washington, DC, May I991.
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INTRODUCTION I am delighted to have been asked to deliver the Kennedy Lecture, named in honor of Dr Robert H Kennedy, a general surgeon who became surgical director at the Beckman-Downtown Hospital in New York City. In that capacity, he was one of the early US trauma surgeons, and from 1939 to I952 he was chairman of the Committee on Trauma of the American College of Surgeons. During the 1950s and 1960s, Dr Kennedy turned his attention to what would now be called prehospital care, in particular, the care of critically injured patients. His efforts included improvement of emergency departments and the building of better bridges between them and the inpatient units, which today are ealted trauma centers. Although today's emergency medicine and trauma surgery have evolved into separate specialties, their connection remains inextricably close, and the path from prehospital care to emergency care and trauma care that was so carefully charted by Dr Kennedy clearly has eanaed him the title of father of emergency medicine. I was present at the initial negotiations that created the American Board of Emergency Medicine, a conjoint board, I must confess that I was not convinced that emergency medicine embraced the unique body of knowledge that warranted separate board status. I also was not sanguine about separate residencies in emergency medicine because sometimes they were not located in quality academic settings. Based on my visits to many medical residency programs as part of the American Board of Internal Medicine's program to evaluate clinical competence, I found that emergency medicine residents often got the dregs of internal medicine rotations. The situation in surgery was even worse. I have not been close to that situation for some years now, and I hope you have improved the lots of your residents when they are on medical and surgical rotations.
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I have become a convert to emergency medicine because of your discipline's fundamental and unique contributions to prehospital care. This development has not only accrued to the benefit of patients but also has opened a new field of research, resulting in major advances in public education. The strong scholarship manifested by your specialty has catapulted it into academic prominence. As a consequence, there has been better acceptance of emergency physicians by academic internal medicine and, although perhaps more reluctantly, by academic surgery. Members of your organization - - Bill Baxt, Paul Pepe, and Mickey Eisenberg - - have worked hard to make me a convert to academic emergency medicine, and I am grateful to them for their proselytizing. In fact, my appreciation of emergency medicine led me to support - - first as an individual and then in behalf of the Association of American Medical Colleges (AAMC) - - autonomous board status for emergency medicine several years before it was approved. In preparation for this lecture, I did a good deal of reading, mostly dealing with present, past, and future activities in the field of academic emergency medicine. Because you communicate with one another freely and frequently, I suspect that you are already familiar with these developments. Therefore, I would like to discuss with you two issues not so frequently mentioned in your writings, graduate medical education and how emergency medicine is involved in this complex process and emergency medicine's academic structure and function, including a discussion of how such a new academic discipline can cope with some of the arcane practices of the academic establishment. Today, the major issues in graduate medical education are physician supply, geographic maldistribution, minority representation, primary care, financing and cost, foreign medical graduates, and accountability.
A G G R E G A T E P H Y S I C I A N SUPPLY The Council on Graduate Medical Education, a quasigovernmental committee, has concluded that there is now or will soon be an oversupply of physicians, l The council says that this oversupply probably would have no socially undesirable consequences. Speaking personally, I am not convinced that the notion of oversupply is not harmful. We already know that it has not driven down physicians' fees as many economists had hoped it would; it has not motivated physicians to practice in underserved areas; and it surely has not decreased health care costs. In fact, there is a view now that the number of physicians in practice, or even the consistently rising physician-to-population ratio, has
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become increasingly irrelevant. What policymakers are looking for is a mitigation of health care costs, which continue to rise at a double-digit annual rate. As long as this is the case, they do not care how many physicians there are. It seems unlikely to me, however, that as long as we deluge the community with subspecialists, costs will do anything other than escalate. It also is conventional wisdom that the federal government should not influence physician supply and that if a reduction is to be made, it should be made at the medical school rather than housestaff level. Regrettably, I have seen no data to refute the contention that a progressively increasing supply of physicians is inevitable. On the supply side, the number of physicians being graduated from medical schools is not decreasing appreciably and the supply of physicians is increasing much more rapidly than the population. Although I admit that we cannot predict what physician demand will be, I find it difficult to believe that the demand will rise as briskly as will the supply. I differ with the notion that the only way in which physician supply should be reduced is by cutting back on the entering class of medical schools. There still is a relative surplus of housestaff positions compared with graduates of schools approved by the Liaison Committee on Graduate Medical Education, and to the extent that filling these positions requires importing physicians who will eventually enter an already overcrowded workplace, it is potentially harmful. Much as we would have it be otherwise, graduate medical education positions are created and allocated primarily on the basis of hospital service needs. As long as that is the case, housestaff positions will continue to exceed the number of US medical school graduates. Emergency medicine may be an exception to the overall manpower picture. A decade ago, a deficit of about 4,000 to 5,000 emergency physicians was projected. In emergency medicine, even the supply side is difficult to estimate because not all emergency physicians come out of emergency medicine training programs. There are many internists among emergency physicians, as well as a few surgeons and pediatricians. According to the AAMC's graduation questionnaire, US seniors planning certification in emergency medicine increased from 3.5% in 1986 to 4.1% in 1989. 2 Data derived from the National Resident Matching Program corroborate the results of this questionnaire. In 1985, 221 US seniors opted for PGY-1 emergency medicine positions. By 1990, that number had risen to 380. In addition, in 1990, 111 US seniors opted for emergency medicine during the second postgraduate year. Between 1990 and 1991, US seniors entering emergency medicine increased by 80,
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from 411 to 491. By comparison, internal medicine categorical training programs lost 143 individuals between 1990 and 1991 (AG Swanson, personal communication, 1991). Despite this salubrious picture on the supply side, the demand side of the equation is no more clear in emergency medicine than it is in any other specialty. You probably know much more than I do about the volume necessary to sustain an emergency medical service, including its prehospital phase, but it surely will be some time before there are enough emergency physicians to meet this need.
GEOGRAPHIC MALDISTRIBUTION It is accepted wisdom that there are too few physicians in rural areas and in the inner city, but this conclusion can be qualified by the statement that things are better than they were 20 years ago. It is certainly true that medicine has become highly sophisticated in a significant number of rural areas. By the 1980s, in many communities with a population of 10,O00 to 30,000, hospitals took on most of the characteristics of tertiary care medical centers. The issue of rural undersupply retains great political currency because if only one rural county in a congressional venue loses its physician or fails to attract one, the matter literally becomes a "federal ease," often complete with new legislation. The situation in the inner city is more complex because of the city's social blights - - drug abuse, murder and other violent crimes, poverty, homelessness, and old age. Academic medical centers cannot solve these problems. Emergency physicians are at particular risk of inner-city violence. Until we solve some of the urban societal blights, or at least attack them with vigor and effectiveness, I doubt that many physicians will voluntarily work in the inner city, and certainly not in the numbers needed. How to address geographic maldistribution remains an enigma. Although it would be nice to select medical school students who will "return to the farm," experience has taught us that they are unlikely to do so once they have seen the city. Perhaps the novel and provocative experiment in medical education put in place at the University of New Mexico and encompassing significant rural clerkship time will succeed. Loan forgiveness programs have been attempted and usually have not worked, but perhaps now that average student debts are approaching $50,000, loan forgiveness programs might be more successful. I think that the National Health Service Corps is one answer to the geographic maldistribution problem, and when it was at its peak, a number of physicians who were forced to interrupt their residency train-
which they had been assigned once they completed their training. It may be an impossible dream to have physicians who are upper-middle class, urban, highly educated, and presumably in need of cultural experiences such as museums or concerts stay on the farm. Rural citizens may have to recognize that the best theycan hope for is access to care provided by rotating physicians discharging a societal obligation. I could not find much about rural emergency medicine. I doubt that most rural communities, with their tiny hospitals and relatively unsophisticated facilities, can sustain emergency services. However, triage facilities modeled on urban emergency systems that have been pioneered so successfully by your specialty must be part of the future.
MINORITY REPRESENTATION It is clear that minorities are under-represented in medicine. That we need to cmTect these inequities also is not arguable. The number of applicants to medical school has decreased (although it has rebounded recently), and the decrease in under-represented minorities has paralleled that of the majority. Although Affirmative Action programs in our medical schools have become more sophisticated, the attrition of minority students is about 11%, whereas it is 1% to 2% among majority students. We also must address the consistent failure of minorities to do as well in the National Resident Matching Program as their colleagues in the majority do. Although the statistics have improved slightly since 1985, the disparity remains great. The pathogenesis of this syndrome is quite straightforward. Although admission committees of medical schools have well-developed Affirmative Action programs, housestaff selection committees do not. Most of our minority medical students get through medical school, but few of them end up in the upper third of the class, which is the target population for most residency program directors. As a consequence, minorities are under-represented in our elite training programs, and many of them are unmatched, at least initially. To correct this problem requires a well-conceived Affirmative Action program that will recruit a cadre of minority housestaff. Once on the scene, minority housestaff tend to recruit their own successors. Like every other specialty, emergency medicine is dominated by Caucasians, and according to the AAMC graduation questionnaire, 81.4% of individuals who entered emergency medicine programs last year were Caucasian. This compares with 80% for all specialties. Emergency medicine attracted more blacks 1~
ing to serve in the Corps returned to practice in the region to
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(7.7%) than did other speciahies but fewer Hispanics and only half as many Asians as did other specialties.
PRIMARY CARE It is the prevalent opinion that there is a shortage of primary care specialists, particularly family physicians and general internists, but not, at the present time, pediatricians. The solution to the problem is obvious: We need to have more of our graduates opt for one of the primary care specialties. Unfortunately, that is not happening. We should recall that in 1987, a significant decrease in US graduates entering internal medicine occurred. An even sharper relative decrement of US graduates who entered family practice occurred in the spring of 1988. For both medicine and family practice, the downward trend continued in 1991. The largest number of US seniors matched into categorical, threeyear internal medicine programs was 3,884 in 1985. In 1991, 2,685 were matched into categorical programs, a 31% decrease. For family practice, there has been a 21% decrease from a high level of 1,728 US seniors matched in 1987. The matching results that were announced in March 1991 showed a further migration into anesthesiology, emergency medicine, and radiology (AG Swanson, personal communication, 1991). Although not all are convinced, anecdotal reports by knowledgeable program directors appear to indicate that finances are playing an ever greater role in the choice of specialties - - perhaps not so much the level of indebtedness as income anticipation. When published data indicate that the median income for neurosurgeons is in excess of $200,000 while that for family physicians is $80,000, it is difficult not to sympathize when the individual with a $75,000 debt opts for one of the more lucrative specialties. There are also different expectations in lifestyle among our young people. They simply want more time for family, significant others, hobbies, and extramedica] activities than did previous generations. In my experience, emergency physicians are compensated better than are general internists and pediatricians, and the scheduled hours of your specialty satisfy the lifestyle requirements of most young physicians. I understand that the emergency medicine community wishes the specialty to be included with the primary care specialties. I do not know the motivation for this request except perhaps the hope of qualifying for manpower grants. However, these programs are so poorly financed now that I doubt that any new specialty would derive much benefit from a pie that is already sliced so thinly. More important, however, emergency medicine does not fulfill the definition of primary care. It is first-contact care, and it
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encompasses the breadth normally expected of a primary care physician, but it does not meet the condition of ongoing relationships with patients. You should not want your specialty to be defined as a primary care specialty, and you should not be offended by this exclusion. I have lived through the era in which every specialty, including ophthalmology, rehabilitation medicine, and child psychiatry, wanted to be defined as a primary care specialty. Fortunately, this fad has passed because specialties have found that it has not made any difference to their future to not be designated as primary care. You, too, can live without emergency medicine being called a primary care specialty. At the other end of the spectrum, you should not attempt to impinge on the subsubspeciahies of critical care medicine and trauma surgery'. I know there have been attempts to move in that direction, and I believe they are as unrealistic and unwise as the quest to classify emergency medicine as a primary- care specialty. Short of indentured service, I do not know how to attract more people into general internal medicine or family practice. The elitism, prestige, and money that accrue to the subspeciahies, all of which are symbolized by that second or, nowadays, third certificate hanging on the wall, have a major influence on career choice. I wonder whether a redistribution of income in which all internists, generalists as well as specialists, would earn equal incomes would put a brake on the continued flight into the specialties. In my view, reimbursement to specialists is associated with too great a financial incentive, in particular, for performing procedures. The necessary first corrective step is to mitigate the financial advantages of doing them. The resource-based relative value scale is, of course, meant to correct these inequities. It will accomplish that but to a limited extent. I doubt that it will also stem the flow of medical school graduates to the medical or surgical specialties, or to anesthesiology, pathology, and radiology. I wonder, sometimes whimsically, what would have happened if we did not have all of those subspeciahy boards. Presently, the boards are caught up in an epidemic of "certifimania" that is likely to lead to even more subspecialization. In medicine, for example, clinical electrophysiology has been put into practice, and transfusion medicine and sports medicine have been proposed; in pediatrics, pediatric radiology and pathology are soon to be instituted; and in orthopedics, trauma and surgery of the spine are considered. For a little while before its withdrawal, there was nonoperative orthopedics. Next, it will be geriatric cardiology - - not cardiology for old people, but for cardiologists who have grown so old in fulfilling training and subcertification requirements that they qualify for geriatric status.
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An exception to certifimania are the plans by the American Board of Internal Medicine and the American Board of Pediatrics to network with the American Board of Emergency Medicine to issue certificates of special qualification in emergency medicine. Given the large number of board-certified internists and an increasing number of pediatricians already staffing EDs, this dual certification makes eminent good sense. F I N A N C I N G AND C 0 S T Funding for graduate medical education may be eroding as payments for patient care have contracted. Ideally, we should continue to use present sources at present levels and, in particular, protect the primary care specialties from cutbacks. The Omnibus Budget Reconciliation Act of 1986 recommended a modest cutback in funding for advanced training. For exampie, for internal medicine, 50% of the second year of subspecialty training would not be reimbursed by Medicare and Medicaid. This provision of the act was not implemented until October 1989, and it is too early to gauge its impact. The administration has proposed more radical changes in its fiscal year 1992 budget proposal. The proposal mandates an average national rate for housestaff compensation. Hospitals will be reimbursed for residency slots in specialties that are deemed to be in surplus at 100% of this national rate and reimbursed for specialties that are deemed to be scarce (eg, child psychiatry) or socially desirable (eg, family medicine) at 240%. The hope is to tilt specialty distribution toward primary care. This strategy might work if there were not already more primary care specialty slots than can be filled. It is not clear to me how hospitals can force young physicians to select primary care specialties as long as there are more slots than there are applicants. As much as I favor the training of more primary care physicians, I do not think that this goal can be achieved by manipulating hospital reimbursement.
COST OF GRADUATE MEDICAL EDUCATION The cost of graduate medical education varies widely, and there is sizable variation in what different hospitals charge Medicare for graduate medical education. These differences reflect primarily what faculty costs are loaded into the equation and how much of the educational infrastructure costs - - the library, conference rooms, housestaff quarters, and so on - - are considered in the reimbursement formula. On the surface, one might think that the hospitals with higher residency costs provide better supervision for their residency training programs, but there is no evidence that this is the case. Institutions with high direct graduate medi-
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cal education costs are usually those in which the medical school does not contribute much to the salaries of the faculty in clinical departments. It then remains for the hospital to carry the financial load. Emergency medical services are almost always financed by hospitals, and their success depends on the hospital breaking even. EDs usually make money and often cross-subsidize other parts of the hospital's operation. They usually can also support a residency program and its associated faculty costs. However, the prehospital part of the package is quite a different matter. I know few trauma centers or hospitals that offer extensive prehospital services that do not lose money on them and require massive subsidy either from the hospital or from public funds. Another issue that emergency medicine has to face, and one that almost surely will be the subject of much scrutiny, is the fact that in many instances not involving critically ill or injured patients, ED care is very expensive care. For example, a member of my family had three ED visits for asthma during the past six months. Each visit lasted about two hours; one was in a statesupported university hospital, the second in a nonaffiliated community hospital, and a third in a private university hospital. All were competently handled by private physicians and, in two instances, housestaff. The costs for a two-hour visit were $524, $646, and $439, respectively. Constraints on heahh care costs will inevitably affect emergency medicine, and these constraints, including poor reimbursement for ambulatory medicine in general, will have an impact on emergency services. A second factor dealing with the funding of graduate medical education is the indirect medical education adjustment. This is a charge to Medicare that is calculated on a resident-per-bed formula and, to put it candidly, has contributed in no small part to the relatively healthy fiscal positions in which, until recently, many teaching hospitals have found themselves. This adjustment is a surrogate for the greater severity of illness in patients in teaching hospitals and the greater intensity of services - - including emergency services offered by these hospitals. A number of factors helped teaching hospitals do well financially in the early years of prospective payment. More recent data show, however, that many teaching hospitals suffered significant Medicare losses this year, and even greater losses are projected in the years ahead. During the first five years of prospective payment, there has been a steady downward trend in actual and projected margins by all types of hospitals. Total margins are particularly low for major teaching hospitals, which tend to accept a larger number of indigent patients who are not part of the Medicare system.
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The Society for Academic Emergency Medicine has taken the same position as the AAMC vis-a-vis the indirect medical education adjustment. Likewise, emergency medicine has opposed the differential reimbursement of hospitals for different specialties. We applaud this political involvement by your organization.
ACCOUNTABILITY Resident hours and supervision continue to be a constant agenda item in any discussion of graduate medical education. Public attention has focused the discussion on hours; even within our community, the issue of hours has tended to generate the most heat, if not the most light. However, I am very much concerned that the discussions of hours and their limitation, call schedules, and time off have tended to obscure a much more serious issue - - supervision of residents. Faculty supervision and faculty participation in graduate medical education are just as likely as the issue of hours to generate complaints fiom young physicians. This seems to be especially true when clinical faculty have divided loyalties between their paying practices and public patients. The association has already taken a position on hours, and we will continue to work to achieve consensus around that position. 3 We must now focus attention on the more important issue of supervision. Many feel that our profession lost esteem in the public's eye during the debate on housestaff hours, but I believe that an even greater injury could be done to the image of academic medicine should some of the neglect of supervision in graduate medical education become known. I believe it is incumbent on all of us, including the AAMC as the representative of professional medical educators, to increase accountability in graduate medical education. The resident bulletin that was sent to me indicated that your resident organization backed the American Medical Association resident section's position that advocates one day off a week and every third night on call. The AAMC advocates an 80-hour workweek - - encompassing true hours of work, not hours on call. The end result is the same. You cannot limit a workweek to 80 hours without at least one day off a week and every third night on call. The reason the AAMC did not favor the one day a week off is that along with our surgical colleagues, we believe some patients require daily rounds even if the resident comes in for only one hour on Sunday. The importance of supervision in the ED cannot be emphasized too strongly. In fact, we might never be in the hours/supervision
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mess if Libby Zion had received adequate ED care. I reviewed that ease carefully, and the second-year resident in medicine never called an attending to see the patient to verify his impression. As a consequence of the Libby Zion ease and the events that followed in its wake, New York State has promulgated and implemented regulations that require ED supervision by an attending. This part of the regulation has been implemented and cannot help but have a salutary effect on ED care. There are also accountability issues at the national level. Sometimes the Accreditation Council on Graduate Medical Education (ACGME), and often the specialty boards, promulgate costly new rules, regulations, and requirements. By and large, these have to be paid for by teaching hospitals. An example of a potential ACGME excess was the mandate to install computerized data processing in every clinical laboratory in teaching hospitals. Some teaching hospitals simply could not afford it. Equally troublesome is the addition of training requirements as a prerequisite for certificates of added or special qualifications by the specialty boards. This additional training usually requires additional funding, funding that in this fiscally constrained environment neither the hospital nor the medical school can provide. There presently is great unrest within the graduate medical education community about the general requirements for residency training that must be adopted by the ACGME and its operation. Although the controversial provision of the general requirements relates to housestaff hours, many are casting the debate not on the substance of the issue - - should housestaff hours be limited, and, if so, how? - - but rather on the principle of autonomy and control - - should the matter of housestaff hours be included in the general requirements at all? A number of the surgical boards, supported by other members of the American Board of Medical Specialties, argue that housestaff hours are more appropriately considered in the special requirements of each clinical discipline. The inability to agree on compromise language on this issue has led to other manifestations of dissatisfaction with the current accreditation of graduate medical education. These include proposals to incorporate the ACGME as an independent organization and to sever the role of the American Medical Association as its host agency. A re-examination of the dual role of the American Medical Association in graduate medical education accreditation through participation in both the residency review committees and the ACGME also has been proposed. At this time, these policy issues remain unsettled, but they must be resolved.
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SUMMARY
case to the American Association of University Professors. Five
I hope this overview of graduate medical education sends the
years later, the American Association of University Professors rendered a decision in favor of the faculty member and censured
message that although we have a system that, in general, ensures high-quality training programs and, by extension, the individuals
the institution, a gesture that had little meaning. The best advice
trained in them, there is work to be done by the academic
I can give you is not to worry at all about tenure. In 1984, I wrote
medicine community. What we must do now is see that this system of graduate medical education is more responsive to society's
an article entitled "The Case Against Tenure in Medical
needs and is more attuned to the practice of medicine that will
is nothing more than an employment policy, and an incomplete
evolve in the next decade and, indeed, in the next century.
one at that. For the most part, the university is responsible for
ACADEMIC ISSUES FACING EMERGENCY MEDICINE As many of your publications have pointed out and as I have alluded to, emergency medicine is a young specialty. In the 20 years of your existence, you have enjoyed some spectacular successes, including: • An autonomous examining board that is now highly respected • Improving and burgeoning residency programs • Increasing popularity among US medical graduates and a higher match rate than ever before • Outstanding prehospital programs, including high-tech trans-
Schools. ''4 In it, I pointed out that in clinical departments, tenure
only part of the faculty member's salary. Failure to obtain tenure means very little because faculty cannot live on the tenured portion of the salary, and, conversely, a loss of academic tenure usually would not affect the faculty member's income because it comes primarily from nonuniversity sources. Because salaries of emergency medicine faculty emanate primarily from the hospital, tenure does not really enter into the equation. Furthermore, tenure does not ensure excellence; on the contrary, it can perpetrate mediocrity. Clinicians can gain enough security with proper contractual arrangements, and these are much more in tune with what they do than is tenure.
portation such as helicopters and fixed-wing aircraft. Better
PROMOTION
prehospital care has resulted in better outcomes of patients
Issues of promotion may pose difficulties for faculty members in departments of emergency medicine. My best advice here is for
with acute trauma and sudden cardiac arrhythmias, in particular, vedtricular fibrillation. In addition, you have done the following: • Been instrumental in making the public more sophisticated and knowledgeable by instructing them in resuscitation techniques • Concentrated on improving emergency medical services instruction and experiences for medical students. Indeed, you have come a long way from my day, when emergency medicine meant mainly learning how to sew up lacerations. • Devised a structured learning experience for rotating residents • Created several professional societies that appear to get along with one another. If you have turf wars, they are not evident from your publications. There are, however, a number of issues about which you should be concerned.
TENURE That the issue of tenure should be of concern to you caught my attention through the story in one of your publications about an assistant professor of emergency medicine who was promised a promotion on which the school ultimately reneged. He took his
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you to opt for a clinical or alternate track, which is more in tune with what most emergency physicians do. Although many emergency physicians have done admirable research and continue to do so, they should not have to endure the constant pressure to do research. Investigation done under such circumstances is often pedestrian and hurried. It is important that the clinical or alternate track has clearly defined criteria that must ensure excellence, but they also must differ from the standard academic requirements. The bottom line is that you should enjoy security and you should be promoted, but you should realize that much of what you do is vastly different from the c]oners and sequencers, and your academic title should reflect that difference.
BROADENING THE RESEARCH PORTFOLIO Many of you have done impressive work on prehospital phenomena, in particular, involving the fields of trauma and cardiac diagnosis and resuscitation. You have also done well in documenting the outcome of prehospital intervention. My plea to you is to look at other events, including improving diagnosis and therapy in EDs, better follow-up of patients seen in the ED, and the cost of emergency services both inside and outside the hospital. I
I~
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have already alluded to high ED costs. At the same time, in my community at least, prehospital care provided by the District of
other clinical departments, occasionally even a basic science
Columbia Fire Department is ludicrously inexpensive. You have
department, or a school of public health. Because many emergency physicians had a previous life in another clinical specialty
made a fine beginning by having residents accepted into the
or even a basic science, the idea of maintaining laboratory skills
Robert Wood Johnson Clinical Scholars Program. Not only should you retain those residents in emergency medicine, but
and productivity in that basic science is occasionally useful. I recall one instance in which an emergency physician who was
you should recruit others from Robert Wood Johnson and similar
well trained in infectious disease continued to round in infec-
programs to engage in health services and health policy research
tious disease. You should consider working in administration,
pertinent to your discipline.
and you should serve on medical school committees. Become an academic mingler and a better academic citizen.
INSTITUTIONAL EMERGENCY
STATUS
OF
MEDICINE
CONCLUDING
REMARKS
Emergency medicine exists under many administrative arrangements. There are a few freestanding medical school departments
In considering the progress your specialty has made in the time frame of a single generation, one can only invoke the ad for
of emergency medicine but many freestanding hospital EDs. I
Virginia Slims (undoubtedly a no-no nowadays) - - "You've come
saw in your publications that a new program was granted consid-
a long way, baby."
erable autonomy as a freestanding division of the dean's office, which is often a precursor to departmental status. Some emergency medicine operations are divisions of the departments of
When I left New Haven Hospital, I was presented with an etching of the old hospital, its pillars now barely visible from the outside because they have been surrounded by new construction.
medicine, surgery, or pediatrics, or they can be sections of a division of general internal medicine. I expect that if the leaders of
When I left the University of Washington 20 years later, I was given a photograph of an aerial view. There were now many
emergency medicine had their druthers, they would opt for an independent academic department. I arn not sure that indepen-
buildings where a golf course had been when I arrived there in 1960.
dent departmental status has not become a fetish and a status symbol. Indeed, many divisions of orthopedics, neurology, ENT, and dermatology, to name just some, that have gained indepen-
When I left the Brigham and Women's Hospital, I was given a sketch of the new unit into which I had shepherded the occupants of old facilities.
dent departmental status have found it to be more desirable in
My favorite farewell memento, however, is a picture of the emergency services helicopter at University of California San
expectation than in fact. The detet~nination of where emergency medicine fits in the academic medical center must ensure not only your comfort and that of your taeulty but also that of the institution. An institution that accepts a new program grudgingly often shows its discomfort by action toward that group. Therefore, by insisting on departmental status, you may have won the battle but lost the war. The bottom line is to find a setup that makes both the faculty and the institution comfortable.
BEING
PART
OF T H E
ACADEMIC
Diego. So you see, ] have come a long way, too.
•
REFERENCES 1. Councilon GraduateMedicalEducation:First Report of the Council,Vol I. Washington,DO,US Departmentof Healthand HumanServices.July 1, 1988. 2. NRMPData. Evanston,Illinois, NationalResidentMatchingProgram,April 1991. 3. PetersdorfRG, BentleyJD: Residents'hoursand supervision.AcadMed1989;64:175 181 4. PetersdorfRG:The caseagainsttenure in medicalschools.JAMA 1984;251:920-924.
SCENE
As a result of my visits to and inspections of academic institutions, one of my greatest concerns about emergency medicine is its tendency toward academic isolation. For the most part, emergency physicians associate only with their colleagues, who have different hours and lifestyles than do physicians in other specialties. The regular faculty consider you outliers and do not really know you. I believe you need to mitigate this tendency. The best way to do this is by collaborative research, whether it is with
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academic emergency medicine
T e Place of EmergencyMedicinein the Academic Community From the Association of Arrverican Medical Colleges, Washington, DC.
Robert G Petersdorf, MD
[Petersdorf RG: The place of emergency medicine in the academic community. Ann Emerg Med February 1992;21:193-200.]
Adapted from the Robert H Kennedy Lecture at the Societyfor Academic Emergency Medicine Annual Meeting in Washington, DC, May I991.
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INTRODUCTION I am delighted to have been asked to deliver the Kennedy Lecture, named in honor of Dr Robert H Kennedy, a general surgeon who became surgical director at the Beckman-Downtown Hospital in New York City. In that capacity, he was one of the early US trauma surgeons, and from 1939 to I952 he was chairman of the Committee on Trauma of the American College of Surgeons. During the 1950s and 1960s, Dr Kennedy turned his attention to what would now be called prehospital care, in particular, the care of critically injured patients. His efforts included improvement of emergency departments and the building of better bridges between them and the inpatient units, which today are ealted trauma centers. Although today's emergency medicine and trauma surgery have evolved into separate specialties, their connection remains inextricably close, and the path from prehospital care to emergency care and trauma care that was so carefully charted by Dr Kennedy clearly has eanaed him the title of father of emergency medicine. I was present at the initial negotiations that created the American Board of Emergency Medicine, a conjoint board, I must confess that I was not convinced that emergency medicine embraced the unique body of knowledge that warranted separate board status. I also was not sanguine about separate residencies in emergency medicine because sometimes they were not located in quality academic settings. Based on my visits to many medical residency programs as part of the American Board of Internal Medicine's program to evaluate clinical competence, I found that emergency medicine residents often got the dregs of internal medicine rotations. The situation in surgery was even worse. I have not been close to that situation for some years now, and I hope you have improved the lots of your residents when they are on medical and surgical rotations.
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I have become a convert to emergency medicine because of your discipline's fundamental and unique contributions to prehospital care. This development has not only accrued to the benefit of patients but also has opened a new field of research, resulting in major advances in public education. The strong scholarship manifested by your specialty has catapulted it into academic prominence. As a consequence, there has been better acceptance of emergency physicians by academic internal medicine and, although perhaps more reluctantly, by academic surgery. Members of your organization - - Bill Baxt, Paul Pepe, and Mickey Eisenberg - - have worked hard to make me a convert to academic emergency medicine, and I am grateful to them for their proselytizing. In fact, my appreciation of emergency medicine led me to support - - first as an individual and then in behalf of the Association of American Medical Colleges (AAMC) - - autonomous board status for emergency medicine several years before it was approved. In preparation for this lecture, I did a good deal of reading, mostly dealing with present, past, and future activities in the field of academic emergency medicine. Because you communicate with one another freely and frequently, I suspect that you are already familiar with these developments. Therefore, I would like to discuss with you two issues not so frequently mentioned in your writings, graduate medical education and how emergency medicine is involved in this complex process and emergency medicine's academic structure and function, including a discussion of how such a new academic discipline can cope with some of the arcane practices of the academic establishment. Today, the major issues in graduate medical education are physician supply, geographic maldistribution, minority representation, primary care, financing and cost, foreign medical graduates, and accountability.
A G G R E G A T E P H Y S I C I A N SUPPLY The Council on Graduate Medical Education, a quasigovernmental committee, has concluded that there is now or will soon be an oversupply of physicians, l The council says that this oversupply probably would have no socially undesirable consequences. Speaking personally, I am not convinced that the notion of oversupply is not harmful. We already know that it has not driven down physicians' fees as many economists had hoped it would; it has not motivated physicians to practice in underserved areas; and it surely has not decreased health care costs. In fact, there is a view now that the number of physicians in practice, or even the consistently rising physician-to-population ratio, has
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become increasingly irrelevant. What policymakers are looking for is a mitigation of health care costs, which continue to rise at a double-digit annual rate. As long as this is the case, they do not care how many physicians there are. It seems unlikely to me, however, that as long as we deluge the community with subspecialists, costs will do anything other than escalate. It also is conventional wisdom that the federal government should not influence physician supply and that if a reduction is to be made, it should be made at the medical school rather than housestaff level. Regrettably, I have seen no data to refute the contention that a progressively increasing supply of physicians is inevitable. On the supply side, the number of physicians being graduated from medical schools is not decreasing appreciably and the supply of physicians is increasing much more rapidly than the population. Although I admit that we cannot predict what physician demand will be, I find it difficult to believe that the demand will rise as briskly as will the supply. I differ with the notion that the only way in which physician supply should be reduced is by cutting back on the entering class of medical schools. There still is a relative surplus of housestaff positions compared with graduates of schools approved by the Liaison Committee on Graduate Medical Education, and to the extent that filling these positions requires importing physicians who will eventually enter an already overcrowded workplace, it is potentially harmful. Much as we would have it be otherwise, graduate medical education positions are created and allocated primarily on the basis of hospital service needs. As long as that is the case, housestaff positions will continue to exceed the number of US medical school graduates. Emergency medicine may be an exception to the overall manpower picture. A decade ago, a deficit of about 4,000 to 5,000 emergency physicians was projected. In emergency medicine, even the supply side is difficult to estimate because not all emergency physicians come out of emergency medicine training programs. There are many internists among emergency physicians, as well as a few surgeons and pediatricians. According to the AAMC's graduation questionnaire, US seniors planning certification in emergency medicine increased from 3.5% in 1986 to 4.1% in 1989. 2 Data derived from the National Resident Matching Program corroborate the results of this questionnaire. In 1985, 221 US seniors opted for PGY-1 emergency medicine positions. By 1990, that number had risen to 380. In addition, in 1990, 111 US seniors opted for emergency medicine during the second postgraduate year. Between 1990 and 1991, US seniors entering emergency medicine increased by 80,
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from 411 to 491. By comparison, internal medicine categorical training programs lost 143 individuals between 1990 and 1991 (AG Swanson, personal communication, 1991). Despite this salubrious picture on the supply side, the demand side of the equation is no more clear in emergency medicine than it is in any other specialty. You probably know much more than I do about the volume necessary to sustain an emergency medical service, including its prehospital phase, but it surely will be some time before there are enough emergency physicians to meet this need.
GEOGRAPHIC MALDISTRIBUTION It is accepted wisdom that there are too few physicians in rural areas and in the inner city, but this conclusion can be qualified by the statement that things are better than they were 20 years ago. It is certainly true that medicine has become highly sophisticated in a significant number of rural areas. By the 1980s, in many communities with a population of 10,O00 to 30,000, hospitals took on most of the characteristics of tertiary care medical centers. The issue of rural undersupply retains great political currency because if only one rural county in a congressional venue loses its physician or fails to attract one, the matter literally becomes a "federal ease," often complete with new legislation. The situation in the inner city is more complex because of the city's social blights - - drug abuse, murder and other violent crimes, poverty, homelessness, and old age. Academic medical centers cannot solve these problems. Emergency physicians are at particular risk of inner-city violence. Until we solve some of the urban societal blights, or at least attack them with vigor and effectiveness, I doubt that many physicians will voluntarily work in the inner city, and certainly not in the numbers needed. How to address geographic maldistribution remains an enigma. Although it would be nice to select medical school students who will "return to the farm," experience has taught us that they are unlikely to do so once they have seen the city. Perhaps the novel and provocative experiment in medical education put in place at the University of New Mexico and encompassing significant rural clerkship time will succeed. Loan forgiveness programs have been attempted and usually have not worked, but perhaps now that average student debts are approaching $50,000, loan forgiveness programs might be more successful. I think that the National Health Service Corps is one answer to the geographic maldistribution problem, and when it was at its peak, a number of physicians who were forced to interrupt their residency train-
which they had been assigned once they completed their training. It may be an impossible dream to have physicians who are upper-middle class, urban, highly educated, and presumably in need of cultural experiences such as museums or concerts stay on the farm. Rural citizens may have to recognize that the best theycan hope for is access to care provided by rotating physicians discharging a societal obligation. I could not find much about rural emergency medicine. I doubt that most rural communities, with their tiny hospitals and relatively unsophisticated facilities, can sustain emergency services. However, triage facilities modeled on urban emergency systems that have been pioneered so successfully by your specialty must be part of the future.
MINORITY REPRESENTATION It is clear that minorities are under-represented in medicine. That we need to cmTect these inequities also is not arguable. The number of applicants to medical school has decreased (although it has rebounded recently), and the decrease in under-represented minorities has paralleled that of the majority. Although Affirmative Action programs in our medical schools have become more sophisticated, the attrition of minority students is about 11%, whereas it is 1% to 2% among majority students. We also must address the consistent failure of minorities to do as well in the National Resident Matching Program as their colleagues in the majority do. Although the statistics have improved slightly since 1985, the disparity remains great. The pathogenesis of this syndrome is quite straightforward. Although admission committees of medical schools have well-developed Affirmative Action programs, housestaff selection committees do not. Most of our minority medical students get through medical school, but few of them end up in the upper third of the class, which is the target population for most residency program directors. As a consequence, minorities are under-represented in our elite training programs, and many of them are unmatched, at least initially. To correct this problem requires a well-conceived Affirmative Action program that will recruit a cadre of minority housestaff. Once on the scene, minority housestaff tend to recruit their own successors. Like every other specialty, emergency medicine is dominated by Caucasians, and according to the AAMC graduation questionnaire, 81.4% of individuals who entered emergency medicine programs last year were Caucasian. This compares with 80% for all specialties. Emergency medicine attracted more blacks 1~
ing to serve in the Corps returned to practice in the region to
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(7.7%) than did other speciahies but fewer Hispanics and only half as many Asians as did other specialties.
PRIMARY CARE It is the prevalent opinion that there is a shortage of primary care specialists, particularly family physicians and general internists, but not, at the present time, pediatricians. The solution to the problem is obvious: We need to have more of our graduates opt for one of the primary care specialties. Unfortunately, that is not happening. We should recall that in 1987, a significant decrease in US graduates entering internal medicine occurred. An even sharper relative decrement of US graduates who entered family practice occurred in the spring of 1988. For both medicine and family practice, the downward trend continued in 1991. The largest number of US seniors matched into categorical, threeyear internal medicine programs was 3,884 in 1985. In 1991, 2,685 were matched into categorical programs, a 31% decrease. For family practice, there has been a 21% decrease from a high level of 1,728 US seniors matched in 1987. The matching results that were announced in March 1991 showed a further migration into anesthesiology, emergency medicine, and radiology (AG Swanson, personal communication, 1991). Although not all are convinced, anecdotal reports by knowledgeable program directors appear to indicate that finances are playing an ever greater role in the choice of specialties - - perhaps not so much the level of indebtedness as income anticipation. When published data indicate that the median income for neurosurgeons is in excess of $200,000 while that for family physicians is $80,000, it is difficult not to sympathize when the individual with a $75,000 debt opts for one of the more lucrative specialties. There are also different expectations in lifestyle among our young people. They simply want more time for family, significant others, hobbies, and extramedica] activities than did previous generations. In my experience, emergency physicians are compensated better than are general internists and pediatricians, and the scheduled hours of your specialty satisfy the lifestyle requirements of most young physicians. I understand that the emergency medicine community wishes the specialty to be included with the primary care specialties. I do not know the motivation for this request except perhaps the hope of qualifying for manpower grants. However, these programs are so poorly financed now that I doubt that any new specialty would derive much benefit from a pie that is already sliced so thinly. More important, however, emergency medicine does not fulfill the definition of primary care. It is first-contact care, and it
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encompasses the breadth normally expected of a primary care physician, but it does not meet the condition of ongoing relationships with patients. You should not want your specialty to be defined as a primary care specialty, and you should not be offended by this exclusion. I have lived through the era in which every specialty, including ophthalmology, rehabilitation medicine, and child psychiatry, wanted to be defined as a primary care specialty. Fortunately, this fad has passed because specialties have found that it has not made any difference to their future to not be designated as primary care. You, too, can live without emergency medicine being called a primary care specialty. At the other end of the spectrum, you should not attempt to impinge on the subsubspeciahies of critical care medicine and trauma surgery'. I know there have been attempts to move in that direction, and I believe they are as unrealistic and unwise as the quest to classify emergency medicine as a primary- care specialty. Short of indentured service, I do not know how to attract more people into general internal medicine or family practice. The elitism, prestige, and money that accrue to the subspeciahies, all of which are symbolized by that second or, nowadays, third certificate hanging on the wall, have a major influence on career choice. I wonder whether a redistribution of income in which all internists, generalists as well as specialists, would earn equal incomes would put a brake on the continued flight into the specialties. In my view, reimbursement to specialists is associated with too great a financial incentive, in particular, for performing procedures. The necessary first corrective step is to mitigate the financial advantages of doing them. The resource-based relative value scale is, of course, meant to correct these inequities. It will accomplish that but to a limited extent. I doubt that it will also stem the flow of medical school graduates to the medical or surgical specialties, or to anesthesiology, pathology, and radiology. I wonder, sometimes whimsically, what would have happened if we did not have all of those subspeciahy boards. Presently, the boards are caught up in an epidemic of "certifimania" that is likely to lead to even more subspecialization. In medicine, for example, clinical electrophysiology has been put into practice, and transfusion medicine and sports medicine have been proposed; in pediatrics, pediatric radiology and pathology are soon to be instituted; and in orthopedics, trauma and surgery of the spine are considered. For a little while before its withdrawal, there was nonoperative orthopedics. Next, it will be geriatric cardiology - - not cardiology for old people, but for cardiologists who have grown so old in fulfilling training and subcertification requirements that they qualify for geriatric status.
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An exception to certifimania are the plans by the American Board of Internal Medicine and the American Board of Pediatrics to network with the American Board of Emergency Medicine to issue certificates of special qualification in emergency medicine. Given the large number of board-certified internists and an increasing number of pediatricians already staffing EDs, this dual certification makes eminent good sense. F I N A N C I N G AND C 0 S T Funding for graduate medical education may be eroding as payments for patient care have contracted. Ideally, we should continue to use present sources at present levels and, in particular, protect the primary care specialties from cutbacks. The Omnibus Budget Reconciliation Act of 1986 recommended a modest cutback in funding for advanced training. For exampie, for internal medicine, 50% of the second year of subspecialty training would not be reimbursed by Medicare and Medicaid. This provision of the act was not implemented until October 1989, and it is too early to gauge its impact. The administration has proposed more radical changes in its fiscal year 1992 budget proposal. The proposal mandates an average national rate for housestaff compensation. Hospitals will be reimbursed for residency slots in specialties that are deemed to be in surplus at 100% of this national rate and reimbursed for specialties that are deemed to be scarce (eg, child psychiatry) or socially desirable (eg, family medicine) at 240%. The hope is to tilt specialty distribution toward primary care. This strategy might work if there were not already more primary care specialty slots than can be filled. It is not clear to me how hospitals can force young physicians to select primary care specialties as long as there are more slots than there are applicants. As much as I favor the training of more primary care physicians, I do not think that this goal can be achieved by manipulating hospital reimbursement.
COST OF GRADUATE MEDICAL EDUCATION The cost of graduate medical education varies widely, and there is sizable variation in what different hospitals charge Medicare for graduate medical education. These differences reflect primarily what faculty costs are loaded into the equation and how much of the educational infrastructure costs - - the library, conference rooms, housestaff quarters, and so on - - are considered in the reimbursement formula. On the surface, one might think that the hospitals with higher residency costs provide better supervision for their residency training programs, but there is no evidence that this is the case. Institutions with high direct graduate medi-
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cal education costs are usually those in which the medical school does not contribute much to the salaries of the faculty in clinical departments. It then remains for the hospital to carry the financial load. Emergency medical services are almost always financed by hospitals, and their success depends on the hospital breaking even. EDs usually make money and often cross-subsidize other parts of the hospital's operation. They usually can also support a residency program and its associated faculty costs. However, the prehospital part of the package is quite a different matter. I know few trauma centers or hospitals that offer extensive prehospital services that do not lose money on them and require massive subsidy either from the hospital or from public funds. Another issue that emergency medicine has to face, and one that almost surely will be the subject of much scrutiny, is the fact that in many instances not involving critically ill or injured patients, ED care is very expensive care. For example, a member of my family had three ED visits for asthma during the past six months. Each visit lasted about two hours; one was in a statesupported university hospital, the second in a nonaffiliated community hospital, and a third in a private university hospital. All were competently handled by private physicians and, in two instances, housestaff. The costs for a two-hour visit were $524, $646, and $439, respectively. Constraints on heahh care costs will inevitably affect emergency medicine, and these constraints, including poor reimbursement for ambulatory medicine in general, will have an impact on emergency services. A second factor dealing with the funding of graduate medical education is the indirect medical education adjustment. This is a charge to Medicare that is calculated on a resident-per-bed formula and, to put it candidly, has contributed in no small part to the relatively healthy fiscal positions in which, until recently, many teaching hospitals have found themselves. This adjustment is a surrogate for the greater severity of illness in patients in teaching hospitals and the greater intensity of services - - including emergency services offered by these hospitals. A number of factors helped teaching hospitals do well financially in the early years of prospective payment. More recent data show, however, that many teaching hospitals suffered significant Medicare losses this year, and even greater losses are projected in the years ahead. During the first five years of prospective payment, there has been a steady downward trend in actual and projected margins by all types of hospitals. Total margins are particularly low for major teaching hospitals, which tend to accept a larger number of indigent patients who are not part of the Medicare system.
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The Society for Academic Emergency Medicine has taken the same position as the AAMC vis-a-vis the indirect medical education adjustment. Likewise, emergency medicine has opposed the differential reimbursement of hospitals for different specialties. We applaud this political involvement by your organization.
ACCOUNTABILITY Resident hours and supervision continue to be a constant agenda item in any discussion of graduate medical education. Public attention has focused the discussion on hours; even within our community, the issue of hours has tended to generate the most heat, if not the most light. However, I am very much concerned that the discussions of hours and their limitation, call schedules, and time off have tended to obscure a much more serious issue - - supervision of residents. Faculty supervision and faculty participation in graduate medical education are just as likely as the issue of hours to generate complaints fiom young physicians. This seems to be especially true when clinical faculty have divided loyalties between their paying practices and public patients. The association has already taken a position on hours, and we will continue to work to achieve consensus around that position. 3 We must now focus attention on the more important issue of supervision. Many feel that our profession lost esteem in the public's eye during the debate on housestaff hours, but I believe that an even greater injury could be done to the image of academic medicine should some of the neglect of supervision in graduate medical education become known. I believe it is incumbent on all of us, including the AAMC as the representative of professional medical educators, to increase accountability in graduate medical education. The resident bulletin that was sent to me indicated that your resident organization backed the American Medical Association resident section's position that advocates one day off a week and every third night on call. The AAMC advocates an 80-hour workweek - - encompassing true hours of work, not hours on call. The end result is the same. You cannot limit a workweek to 80 hours without at least one day off a week and every third night on call. The reason the AAMC did not favor the one day a week off is that along with our surgical colleagues, we believe some patients require daily rounds even if the resident comes in for only one hour on Sunday. The importance of supervision in the ED cannot be emphasized too strongly. In fact, we might never be in the hours/supervision
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mess if Libby Zion had received adequate ED care. I reviewed that ease carefully, and the second-year resident in medicine never called an attending to see the patient to verify his impression. As a consequence of the Libby Zion ease and the events that followed in its wake, New York State has promulgated and implemented regulations that require ED supervision by an attending. This part of the regulation has been implemented and cannot help but have a salutary effect on ED care. There are also accountability issues at the national level. Sometimes the Accreditation Council on Graduate Medical Education (ACGME), and often the specialty boards, promulgate costly new rules, regulations, and requirements. By and large, these have to be paid for by teaching hospitals. An example of a potential ACGME excess was the mandate to install computerized data processing in every clinical laboratory in teaching hospitals. Some teaching hospitals simply could not afford it. Equally troublesome is the addition of training requirements as a prerequisite for certificates of added or special qualifications by the specialty boards. This additional training usually requires additional funding, funding that in this fiscally constrained environment neither the hospital nor the medical school can provide. There presently is great unrest within the graduate medical education community about the general requirements for residency training that must be adopted by the ACGME and its operation. Although the controversial provision of the general requirements relates to housestaff hours, many are casting the debate not on the substance of the issue - - should housestaff hours be limited, and, if so, how? - - but rather on the principle of autonomy and control - - should the matter of housestaff hours be included in the general requirements at all? A number of the surgical boards, supported by other members of the American Board of Medical Specialties, argue that housestaff hours are more appropriately considered in the special requirements of each clinical discipline. The inability to agree on compromise language on this issue has led to other manifestations of dissatisfaction with the current accreditation of graduate medical education. These include proposals to incorporate the ACGME as an independent organization and to sever the role of the American Medical Association as its host agency. A re-examination of the dual role of the American Medical Association in graduate medical education accreditation through participation in both the residency review committees and the ACGME also has been proposed. At this time, these policy issues remain unsettled, but they must be resolved.
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SUMMARY
case to the American Association of University Professors. Five
I hope this overview of graduate medical education sends the
years later, the American Association of University Professors rendered a decision in favor of the faculty member and censured
message that although we have a system that, in general, ensures high-quality training programs and, by extension, the individuals
the institution, a gesture that had little meaning. The best advice
trained in them, there is work to be done by the academic
I can give you is not to worry at all about tenure. In 1984, I wrote
medicine community. What we must do now is see that this system of graduate medical education is more responsive to society's
an article entitled "The Case Against Tenure in Medical
needs and is more attuned to the practice of medicine that will
is nothing more than an employment policy, and an incomplete
evolve in the next decade and, indeed, in the next century.
one at that. For the most part, the university is responsible for
ACADEMIC ISSUES FACING EMERGENCY MEDICINE As many of your publications have pointed out and as I have alluded to, emergency medicine is a young specialty. In the 20 years of your existence, you have enjoyed some spectacular successes, including: • An autonomous examining board that is now highly respected • Improving and burgeoning residency programs • Increasing popularity among US medical graduates and a higher match rate than ever before • Outstanding prehospital programs, including high-tech trans-
Schools. ''4 In it, I pointed out that in clinical departments, tenure
only part of the faculty member's salary. Failure to obtain tenure means very little because faculty cannot live on the tenured portion of the salary, and, conversely, a loss of academic tenure usually would not affect the faculty member's income because it comes primarily from nonuniversity sources. Because salaries of emergency medicine faculty emanate primarily from the hospital, tenure does not really enter into the equation. Furthermore, tenure does not ensure excellence; on the contrary, it can perpetrate mediocrity. Clinicians can gain enough security with proper contractual arrangements, and these are much more in tune with what they do than is tenure.
portation such as helicopters and fixed-wing aircraft. Better
PROMOTION
prehospital care has resulted in better outcomes of patients
Issues of promotion may pose difficulties for faculty members in departments of emergency medicine. My best advice here is for
with acute trauma and sudden cardiac arrhythmias, in particular, vedtricular fibrillation. In addition, you have done the following: • Been instrumental in making the public more sophisticated and knowledgeable by instructing them in resuscitation techniques • Concentrated on improving emergency medical services instruction and experiences for medical students. Indeed, you have come a long way from my day, when emergency medicine meant mainly learning how to sew up lacerations. • Devised a structured learning experience for rotating residents • Created several professional societies that appear to get along with one another. If you have turf wars, they are not evident from your publications. There are, however, a number of issues about which you should be concerned.
TENURE That the issue of tenure should be of concern to you caught my attention through the story in one of your publications about an assistant professor of emergency medicine who was promised a promotion on which the school ultimately reneged. He took his
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you to opt for a clinical or alternate track, which is more in tune with what most emergency physicians do. Although many emergency physicians have done admirable research and continue to do so, they should not have to endure the constant pressure to do research. Investigation done under such circumstances is often pedestrian and hurried. It is important that the clinical or alternate track has clearly defined criteria that must ensure excellence, but they also must differ from the standard academic requirements. The bottom line is that you should enjoy security and you should be promoted, but you should realize that much of what you do is vastly different from the c]oners and sequencers, and your academic title should reflect that difference.
BROADENING THE RESEARCH PORTFOLIO Many of you have done impressive work on prehospital phenomena, in particular, involving the fields of trauma and cardiac diagnosis and resuscitation. You have also done well in documenting the outcome of prehospital intervention. My plea to you is to look at other events, including improving diagnosis and therapy in EDs, better follow-up of patients seen in the ED, and the cost of emergency services both inside and outside the hospital. I
I~
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have already alluded to high ED costs. At the same time, in my community at least, prehospital care provided by the District of
other clinical departments, occasionally even a basic science
Columbia Fire Department is ludicrously inexpensive. You have
department, or a school of public health. Because many emergency physicians had a previous life in another clinical specialty
made a fine beginning by having residents accepted into the
or even a basic science, the idea of maintaining laboratory skills
Robert Wood Johnson Clinical Scholars Program. Not only should you retain those residents in emergency medicine, but
and productivity in that basic science is occasionally useful. I recall one instance in which an emergency physician who was
you should recruit others from Robert Wood Johnson and similar
well trained in infectious disease continued to round in infec-
programs to engage in health services and health policy research
tious disease. You should consider working in administration,
pertinent to your discipline.
and you should serve on medical school committees. Become an academic mingler and a better academic citizen.
INSTITUTIONAL EMERGENCY
STATUS
OF
MEDICINE
CONCLUDING
REMARKS
Emergency medicine exists under many administrative arrangements. There are a few freestanding medical school departments
In considering the progress your specialty has made in the time frame of a single generation, one can only invoke the ad for
of emergency medicine but many freestanding hospital EDs. I
Virginia Slims (undoubtedly a no-no nowadays) - - "You've come
saw in your publications that a new program was granted consid-
a long way, baby."
erable autonomy as a freestanding division of the dean's office, which is often a precursor to departmental status. Some emergency medicine operations are divisions of the departments of
When I left New Haven Hospital, I was presented with an etching of the old hospital, its pillars now barely visible from the outside because they have been surrounded by new construction.
medicine, surgery, or pediatrics, or they can be sections of a division of general internal medicine. I expect that if the leaders of
When I left the University of Washington 20 years later, I was given a photograph of an aerial view. There were now many
emergency medicine had their druthers, they would opt for an independent academic department. I arn not sure that indepen-
buildings where a golf course had been when I arrived there in 1960.
dent departmental status has not become a fetish and a status symbol. Indeed, many divisions of orthopedics, neurology, ENT, and dermatology, to name just some, that have gained indepen-
When I left the Brigham and Women's Hospital, I was given a sketch of the new unit into which I had shepherded the occupants of old facilities.
dent departmental status have found it to be more desirable in
My favorite farewell memento, however, is a picture of the emergency services helicopter at University of California San
expectation than in fact. The detet~nination of where emergency medicine fits in the academic medical center must ensure not only your comfort and that of your taeulty but also that of the institution. An institution that accepts a new program grudgingly often shows its discomfort by action toward that group. Therefore, by insisting on departmental status, you may have won the battle but lost the war. The bottom line is to find a setup that makes both the faculty and the institution comfortable.
BEING
PART
OF T H E
ACADEMIC
Diego. So you see, ] have come a long way, too.
•
REFERENCES 1. Councilon GraduateMedicalEducation:First Report of the Council,Vol I. Washington,DO,US Departmentof Healthand HumanServices.July 1, 1988. 2. NRMPData. Evanston,Illinois, NationalResidentMatchingProgram,April 1991. 3. PetersdorfRG, BentleyJD: Residents'hoursand supervision.AcadMed1989;64:175 181 4. PetersdorfRG:The caseagainsttenure in medicalschools.JAMA 1984;251:920-924.
SCENE
As a result of my visits to and inspections of academic institutions, one of my greatest concerns about emergency medicine is its tendency toward academic isolation. For the most part, emergency physicians associate only with their colleagues, who have different hours and lifestyles than do physicians in other specialties. The regular faculty consider you outliers and do not really know you. I believe you need to mitigate this tendency. The best way to do this is by collaborative research, whether it is with
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