by Anthony Rodigin
What is EM?
Emergency Medicine (EM) does not claim its own body part or a physiologic system. With Vascular Surgery or Endocrinology things are straightforward. But what do we have?
Most of our procedures are shared with other specialties. We use many of the same tools and instruments. Emergency physicians also value evidence-based practice. And like providers in other fields, we believe in disease prevention, palliation, empathy, the Hippocratic oath and the magic of human touch.
In some places, emergency medicine is confused with the mere lights and sirens of ambulances or with various types of outpost facilities providing as little as vaccinations and screenings. And even if unmistakable emergency departments (EDs) are present, it is not apparent to many ED patients that the doctors seeing them are not just any doctors from somewhere else in the hospital.
It is easy to say that emergency medicine deals with emergencies. True – we initiate life-saving interventions, commence stabilizing treatments and ultimately supervise the patient’s transition to definitive care. But who is best positioned to select out these emergencies in the first place? And in what other settings besides the ED should our skills be called upon and applied? Real essence of modern EM cannot be understood without thinking through these questions.
So once again, who are we and what is EM?
Evolution of EM
Both prehospital emergency care and ancestral emergency rooms predate the emergency medicine specialty itself. Out of the many wars and civilian side catastrophes came the realization that competent care was needed before and during transport to a hospital. At the same time, early emergency rooms, often small and inconveniently located in basements or on second floors, served as the natural intersection for walk-ins, ambulances and hospital wards in the early and mid-twentieth century.
The technological boom following the Second World War was in part responsible for the transition from outpatient to hospital-based medicine. More could be done and in a quicker time frame inside of a hospital, and the sickest of the sick now perhaps had a chance of survival. A natural demand for expanded and better-equipped casualty (aka accident- or emergency-) departments was created. At the same time, more patients presenting to EDs with non-traumatic complaints underscored the need to move beyond mere trauma and injury.
Still, as the earlier version of this chapter correctly stated, “Only a few decades ago, emergency departments…were staffed by physicians with a variety of training backgrounds. The vast majority of these physicians had little to no emergency medicine training at all. General surgeons, family physicians, neurologists, and even psychiatrists were among those that staffed emergency departments…throughout the world” .
In the 1960s and 1970s things began to change rapidly. As ambulance care and destination decisions improved, in some nations relying on physicians and in others on newly established paramedics, so did the understanding that a dedicated provider specializing in ED services was invaluable. In the United States, pioneer physicians who chose to work exclusively at EDs provided additional advantages to the lifestyles and efficiency of specialists. Freeing up the latter to concentrate on more complex specialty-driven tasks led to their higher reimbursements. Thus, both the absence of competing emergency care physicians in the prehospital domain and economic incentives created by EM for narrow specialties pushed EM development in the US somewhat ahead of other parts of the world. The vast and ubiquitous benefits of EM to the general public were to follow.
From the 1970s and on rapid growth of EM residencies took place, together with the founding and strengthening of EM national boards and EM national and international societies. Brian Zink’s famous “Anyone, Anything, Anytime” comprehensively describes the history of modern EM in the United States . Another excellent resource is this documentary from the Emergency Medicine Residents’ Association (EMRA). Such a trajectory was closely matched by EM’s path in the United Kingdom, Canada, Australia and other culturally Western nations, steadily but surely spreading throughout most of the world.
With every decade that followed, the number of countries developing EM increased exponentially. Arguably, each nation’s own EM chronicles are best regarded and studied in tandem with texts like Ryan Corbett Bell’s “The Ambulance”, which ought to describe the contemporaneous evolution of not only prehospital medicine but of the overall emergency care landscape in each nation as the precise background for EM’s necessity, birth and its coming of age .
Emergency medicine and its place within the emergency care endeavor are not going anywhere, but the scope of EM will undoubtedly change.
We can anticipate with a high degree of probability that, somewhat paradoxically to its origins, EM will continue to expand its reach beyond the emergency department. Very possibly, post-residency training via fellowships will become the norm rather than the exception. Further integration with prehospital services and sharing of EM workplaces with non-physician EM specialists (e.g. Advanced Practice Providers) will persist. Natural and technologically driven disasters will maintain high demand for EM’s unique combination of versatility and focused expertise.
The future may not bring ready solutions to all of the clinging problems. Lack of access to universally accepted standards of emergency care in rural, remote and low-income areas is one. EM’s ambivalently viewed safety net function arising from any healthcare system’s gaps and incapacities in non-EM arenas like primary care and preventative medicine is another example. In addition, proper relationship of EM with other conceptual definitions and terms such as Frontline Medicine, Emergency Medical Services (EMS), Acute Critical Care and Pediatric EM will have to be philosophically teased out further on a global scale.
Finally, an area of medicine that has matured to its most commonly used name of Global Health (GH) needs to be mentioned in this context. Current involvement of EM physicians in GH projects, while not uncommon, is not something universally anticipated. Today it still rests on enthusiasm of individual participants or institutions. The future may call for things to change drastically in the long run.
The prognoses mentioned are not exhaustive, but they should all be met with optimist and eagerness. It is beyond any doubt that unprecedented opportunities await future EM trainees not only through engagement in primary clinical work and research in the ED, but also in domains ranging from local policy making to transnational epidemiology, and vice versa.
Today it can be surmised with justification and pride that the battle for EM’s existence, its independence and its own standards matching or surpassing those of more traditional medical specialties has been largely won.
Distinctive and concrete advantages of EM include flexibility in work schedules and lifestyles and the balance of individual expertise with teamwork. Further, EM offers multiple areas for gaining additional proficiency – ranging from bedside ultrasound to basic research and from business practices to international health. Last but not least, EM features an unparalleled interconnected global community of people just like you. If in doubt, you should strive to attend an EM International Congress (ICEM) or a regional EM conference in your area. See for yourself!
Of course, visible and hidden currents remain in motion, bringing in tides of new trials. Efforts toward fair employment practices, workplace safety, non-malevolent legal climate, job security and sustainability, EM’s influence on healthcare policies – these are only a few of today’s pressing themes. Still, such challenges are neither unprecedented nor unique to EM, and are not anything to be afraid of for future EM clinicians.
Above all else, one should know that EM is an exciting, versatile and dynamic specialty to consider as one’s top choice for a career in medicine.
Who are EM docs?
Our field is not without its stereotypes. A common one is that all EM physicians are adrenaline junkies and type A immediate gratification personalities. When we are not intubating in the ED, we are skydiving or playing extreme sports. In truth, there are as many characters, hobbies and interests in EM as there are in the world at large. The passion in EM that we all share is to be found it its mission. We believe in equal opportunities to receive competent emergency care world-wide and in EM’s unique approach to the undifferentiated patient.
What sets EM physicians apart?
In the next two chapters, you will discover more words of wisdom and advice about why EM is a great choice for a specialty, and how EM physicians think differently from other providers. Here, we will come back to the two questions mentioned at the beginning of this chapter.
The first had to do with the selection of those patients who truly do have urgent, emergent and even life-threatening conditions. Of course, some selection is self-selection, as it happens at the patient’s own home or wherever they happened to be. At other times, primary care, walk-in or ambulance services may be involved and may even play a great part. All countries differ in how the tiers of access to emergency services are designed and staggered. Interestingly and controversially, the ethics of what and to what extent an emergency care system is allowed to miss also varies by locale depending in part on culture, in part on the level of public education and in part on historical precedent shaping expectations.
In general, however, EM does not rely on or trust other types of medical providers to do this selection for us. Our specialty was designed specifically to work with the population at large presenting with all health concerns, worries or issues. These truly can be anything coming from anyone at any time. Thus, at least a third of our jobs is to figure out who truly is at risk no matter what the actual diagnosis. This task relies on a completely different set of skills than dealing with someone you already know is critical. Afterwards, we have to perform the next crucial step and stabilize our sick patients. Like bread and butter, it is hard to imagine our field without both of these essential components of practice intertwined together. Of course, in reality, we do much more than caring only for the very ill, which is the last third. From bedside psychology and social advocacy to primary pediatrics, second opinions and after-hours dermatology – we do it all.
The other question was about applying ourselves beyond the ED. EM skills are not only for the hospital. Over the last few decades, it has become obvious that EM physicians function superbly in multiple other settings, from ground and helicopter EMS (including direction and planning) to disaster relief and event medicine. EM physicians make excellent wilderness docs, public and organizational consultants, surgical assistants on GH medical missions (sometimes functioning as the only “anesthesiologist”), proceduralists, tactical support physicians, academic researchers, critical care and ICU providers and much more. All of these cojoined fields provide and will continue to provide ample opportunities for worldwide EM practice for generations of EM aficionados to come.
So, would you like to join in on the fun?
Listen to the chapter
Cite This Article
Please replace “iEM Education Project Team” below with the author(s) surname and initials.
- Sanderson W., Cuevas D. and Rogers R. “Emergency Medicine: A Unique Specialty”. iEmergency Medicine for Medical Students and Interns. 1st edition, Version 1, 2018.
- Zink, Brian J. “Anyone, Anything, Anytime: A History of Emergency Medicine”, 2nd Edition Hardcover – January 1, 2018
- Bell, Ryan Corbett. “The Ambulance: A History”. Reprint edition, McFarland & Company, Inc., 2009