The Role of Emergency Medicine in the Future of American Medical Care: A Summary of the Josiah Macy, Jr, Foundation Conference
D. Kay Clawson, MDClinical Professor of Surgery/Orthopedics
College of Medicine
University of Kentucky
Lexington, KY
Quick Overview
For readers not familiar with the Josiah Macy, Jr, Foundation Conference concept, this organization has been sponsoring 2- to 4-day invitational conferences on important topics impacting on the education of the public, medical students, and healthcare providers for many years. The published proceedings of the conference are widely read by influential groups, including those involved in health policy. This conference was developed at the request of the Society of Academic Emergency Medicine (SAEM) under the chairmanship of Dr. Thompson Bowles, President of the National Board of Medical Examiners. The Macy Foundation responded because it recognized that the specialty of emergency medicine that had come into being over the past 30 years seemed to be in crisis.
Detailing the history of the development of emergency medicine as a specialty and the conflicts surrounding its development extending to the present day is beyond the scope of this article, and the reader is referred to the Macy publication (1) for background information. In listening to the various concerns of professionals delivering emergency medical care, it is easy to become distracted from the central issue, which is the quality of care available to the American public through our emergency medicine system-or lack of system, as we get involved in ideologic and, more often, economic "wars." Further, the efforts of our government in promoting "one size fits all" and the seductiveness of this concept to many of our specialty organizations have further complicated the development of rational, cost-effective solutions. Emergency medicine, like the specialty of family practice, did not arise via a carefully thought-out plan within our American medical schools and universities. For the most part, the development of the specialities was impeded because they did not represent a discipline centered on an organ system. These specialties arose because of a need perceived by the public sector.
To this day, emergency medicine has not been embraced in all of our medical schools to the degree its importance and contribution to the health and well-being of our society would indicate. In addition to caring for the seriously sick and injured, EDs have increasingly become the principal source of medical care for the poor and the uninsured. When the federal government mandated that any hospital receiving federal funds was required to provide screening examinations for every patient requesting care through their EDs, hospitals began seeking cost-effective mechanisms of achieving that mandate. For a long time, the typical university hospital was able to staff the emergency room with interns and residents. However, private hospitals could not expect busy clinicians to leave their practices to meet this demand, and hence were eager to support the concept of full-time ED physicians. The quality and availability of the physicians attracted to this role varied widely. From this, it was only natural that a new specialty be initiated, in 1978, having a conjoint board that was supported by the American Boards of Surgery, Internal Medicine, Pediatrics, Neurology, and Psychiatry.
In supporting the conference, the Macy Foundation noted that as emergency care had become more sophisticated and complex, the new specialty of emergency medicine had taken on major roles; however, its future seemed poorly defined and its personnel needs unclear.
The six recommendations were endorsed by 32 participants.
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 healthcare 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.
This recommendation recognizes that the work-force needs of this specialty are difficult to predict in a changing healthcare delivery system. While the specialty itself, and many outside the specialty, feel that significantly more emergency physicians need to be trained, COGME and many others feel that if primary care physicians (or in certain scenarios, nurse clinicians or physician assistants) are available to render urgent treatment on a 24-hour basis, then there would indeed be less need for emergency medicine physicians. Therefore, fewer should be trained. More than 12,000 certified emergency medicine physicians have been trained, and the most recent data indicate that there are approximately 775 first-year positions. COGME has recommended that these be cut to 475. The Macy Foundation report stressed that there should be no arbitrary change in the number and, in particular, no reduction in the current number of residency positions in emergency medicine, unless the impact of such changes has been studied and justified within a reformed healthcare system.
3. The Society of 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 new 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 qualification of "moonlighters."
Currently, the United States has an inadequate system for classifying EDs. As a result, it is impossible for the public to know what level of care an ED is capable of providing. In the interest of both protecting and informing the public, a classification system for EDs should be developed that is comparable to the one that rates each hospital-based trauma center on the level of sophistication of care it provides.
The new ED classification system should particularly reflect the qualifications of physicians who staff each ED. The presence of physicians in EDs who are neither adequately nor appropriately trained is not conducive to high-quality emergency care. Yet, many EDs continue to be staffed with physicians trained in specialties other than emergency medicine or with residents in training or with physicians who have as little as (1) year of graduate medical education. The classification of EDs 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 EDs without specialty training in emergency medicine. In addition, many moonlighters lack training and adequate experience in any aspect of primary healthcare.
Since EDs in rural areas may not be staffed with emergency medicine specialists, they 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 EDs 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% 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 that applicants have 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.
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.
Less than 50% 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 of educational programs in emergency care, and also strengthen the collaborative professional relationships necessary for research and for high-quality clinical services in emergency care.
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.
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.
Quick Overview
Additional Observations: Problems and Solutions
1. It is well past time that we restructure the entire medical education process. While American medical schools, with their associated residencies, have been able to produce major advances in healthcare and the highest quality of specialty care, they have failed to produce a sufficient number of physicians trained in the broadest sense to meet the healthcare needs of our society in a humane, caring, and cost-effective manner. In my chairman's address to the Association of American Medical Colleges in 1989, (2) I called attention to the 1932 final report of the Commission of Medical Education,(3) known as the Rappleye. This report was critical of the fact that "teachers were presenting topics of their interest far too much from the technical details and that the fact that the education of the student was focused too much on the rare and serious diseases requiring services of the specialists and advanced laboratory examinations, diagnosis, and treatment."(3)I noted that medical education had changed very little from that time. Faculties and leaders in academic medicine must boldly move forward to reform the medical education process. The two major stumbling blocks to making change are (1) turf issues, epitomized in the specialty departments and the power accorded to department chairs; and (2) tenure, which is interpreted as a lifetime contract-a situation that makes it difficult, if not impossible, to change direction and create new specialties, however badly needed, through appropriate reallocation.
It is virtually impossible for administrators to bring about needed change since medical schools, like universities, delegate responsibility for curricula to their faculties. The faculty maintains a strong identity with its discipline and a strong desire to perpetuate it. Administrators, on the other hand, may see the need for a radical change in direction but can only lead and encourage, for they do not enjoy tenure. Change, therefore, must come from societal pressure, as it did in the creation of departments of family practice and is increasingly doing so in emergency medicine. It makes little sense to attempt to effectively and efficiently care for a cardiac patient by involving emergency medicine physicians, the patient's primary care physician, a cardiologist, perhaps a cardiac surgeon, an anesthesiologist, and others-all functioning in separate departments. Once integration of these separate disciplines is achieved for the benefit of the patient, we will resolve many of the current turf battles.
2. The Residency Review Committee (RRC) and the Accrediting Council for Graduate Medical Education (ACGME) must back off their requirements of six residents per year for an accredited emergency medicine program. No matter how desirable this may be, it is seriously limiting opportunities to start new programs because of the financial implications. Few surgical specialties would have ever gotten off the ground with the demand of six residents per year of training.
3. When we speak of medicine, we tend to refer to allopathic medicine and ignore osteopathic medicine and the role the osteopathic physician has in the delivery of healthcare in this country. There are now more than 35,000 osteopaths in practice, encompassing primary care as well as all of the specialties of medicine and surgery, and their 16 fully or provisionally accredited medical schools are producing more than 2,000 graduates per year. In addition, they operate large and small hospitals providing emergency care, cardiac care, etc. These physicians need to be included in the equation of healthcare and consulted as we develop national, state, and local policies.
4. With or without government intervention, the delivery of healthcare is changing from the independent physician mode of care to the industrialized model. With this comes critical analysis of the most cost-effective methods for delivering an acceptable level of care. For the most part, it is now recognized that despite our efforts to provide the highest quality of care, such care may be too costly. At the same time, while we strive to do this and reach only certain segments of the population, many others-rich and poor alike-do not receive even good quality care. While health professionals are unwilling to accept that any cost is too high if they can save a life, society has increasingly said, "Stop, we don't want to pay more, give us an acceptable 'high' quality of care at a price that we can afford." Leaders in American medicine must look at ways in which they can reorganize the system to provide an acceptable high quality of care for all without breaking the bank by eliminating duplicate services, unnecessary testing and procedures, and unnecessary standby services, even though it may mean closing many EDs and appropriately transporting and routing patients to other centers.
Centers, whether they are trauma centers, cancer treatment centers, transplant centers, cardiac centers, or acute chest pain centers, have a capability that goes beyond that of the standard acute care hospital. An extra 5, 10, or even 30 minutes spent in transport to a center may be well worth it-and is preferable to lying in a poorly staffed emergency room that lacks the appropriate specialty backup to render the full scope of care needed in the emergency situation.
As part of EDs in large urban hospitals, chest pain centers are most effective not only in treating acute cardiac conditions but also in educating physicians, other health providers, and the public in assisting people to obtain treatment before situations become life-threatening. It is equally important for the leaders of the chest pain center movement to recognize that one size doesn't fit all, and assist in the development of standards of care that can be applicable in all EDs, large or small, urban or rural. We should look at different models for altering our delivery system to provide a higher quality of care to all Americans without increasing the cost.
References
1. Bowles LT, Sirica CM, eds. The Role of Emergency Medicine in the Future of American Medical Care. Proceedings of the Josiah Macy, Jr, Foundation Conference, Williamsburg, Va, April 17-20, 1994. New York, NY: Josiah Macy, Jr Foundation; 1995.
2. Clawson DK. The education of the physician. Acad Med. 1990;65:84-88.
3. Rappleye WC. Medical Education: Final Report of the Commission on Medical Education. New York, NY: Association of American Medical Colleges Commission on Medical Education; 1932.
Return to Index of Articles for Clinician;
Volume 14.4
- Faculty Listing 3
- Introduction: Community Message in Acute Myocardial Ischemia 4
- Concept of Community Chest Pain Centers in Emergency Departments 5
- Reawakening Awareness of the Importance of Prodromal Symptoms in the Shifting Paradigm to Early Heart Attack Care (EHAC) 7
- The Role of Emergency Medicine in the Future of American Medical Care: A Summary of the Josiah Macy, Jr, Foundation Conference 12
- From ACC/AHA Guidelines to Best Practice: Can "Acute MI Report Cards" Save Lives?Measuring Quality of Care for Patients With Cardiovascular Disease 16
- Improving Lay Responses to Cardiovascular Emergencies and the Potential of Shifting the Paradigm to Early Heart Attack Care 18
- National Survey of Chest Pain Centers Rationale and Potential Results 21
- Outpatient Rule-Out Myocardial Infarction in Observation Units 22
- Reducing Time to Thrombolytic Treatment 24
- Intervention Programs to Reduce Patient Delays in Acute Myocardial Infarction 29
- Public Education Using the Early Heart Attack Care Program Shawnee Mission Medical Center 31
- School Component: Early Heart Attack Care Program Development and Evaluation 33
- Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction 36
- Precipitating Factors in Acute Cardiovascular Disease 41
- Use of Myocardial Perfusion Imaging in the Emergency Department for Risk Stratification 44
- The Evolution of Chest Pain Centers: The Impact of Technological Advances on the Evaluation of Patients With Possible Acute Ischemic Coronary Syndrome 47
- Critical Pathways for Triage and Treatment of Chest Pain Patients in the Emergency Department 53
- Chest Pain Centers: An Emerging Model for the Emergency Evaluation of Chest Pain and Treatment of Acute Myocardial Infarction 56
- The Key to Success in the Chest Pain Emergency Department: The Observational Role of theNurse 59
- Triage in Moderate Risk Patients With Chest Pain: The Emerging Role of Real-Time Continuous ECG Monitoring 61
- Diffusion of Innovations: The Introduction and Impact of the Chest Pain Emergency
- Department and its Comparison to the Coronary Care Unit Development 64
- Economics of Chest Pain Centers: What Really Matters? 68
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