Wednesday, April 18, 2007
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Tuesday, April 17, 2007
Emergency Medicine as a Career Choice
Christopher Russi, DO
Louis Binder, MD
(Note: This article was provided by SAEM and can be found in it's original form there. It does get updated occasionally, so check it out and the other resources at SAEM!)
Emergency physicians (EP's) believe that quality emergency care should be available to all people who need it. Today there are more than 32,000 practicing EP's with over 21,000 certified by the American Board of Emergency Medicine (ABEM) and American Osteopathic Board of Emergency Medicine (AOBEM).1,2 With approximately 114 million annual emergency department (ED) visits in approximately 5000 hospitals, the demand for board certified EP's is greater than the current supply.3 Current projections are that this shortage will last at least through the year 2030.4 Since emergency medicine (EM) is one of the newest and most rapidly developing specialties, there are ample opportunities for the new physician who wants to enter this challenging and rapidly evolving branch of medicine.
Historical Background
Within the "house of medicine," EM is a relatively new specialty which has evolved over the last 35 years. For many years, hospitals provided emergency care as an obligation, seeing no profit or marketing through goodwill. In the 1960's, such care consisted of an "emergency room" operated by the nursing supervisor, who might dispense care and medications via physician telephone orders or, in an extreme case, call in a junior house officer or physician from home. The medical equipment used was usually passed down from other services. Accident victims received no prehospital care and were often transported to the hospital in the undertaker's hearse.
The American College of Surgeons (ACS) was among the first groups of physicians to recognize the need for organized emergency services. The ACS published progressive recommendations, but no specialties were willing or able to enact these recommendations, because the concept of a comprehensive ED did not fit within the scope of any established specialty. As patient demand for quality emergency care increased, more physicians began to staff ED's. In 1968, a budding young group of EP's joined together to found the American College of Emergency Physicians (ACEP). In 1970, the first EM residency began at the University of Cincinnati, and many more across the country were establish in the coming years. ACEP worked diligently during the 1970's to achieve specialty status for these new residency graduates. A core content of knowledge and skills for EM was established; a specialty journal, now known as the Annals of Emergency Medicine was founded; textbooks were written; an interim Residency Review Committee (RRC) was initiated; and continuing medical education courses were offered. Finally, in 1979, when all the necessary factors were in place, EM was recognized as medicine's newest specialty by the American Board of Medical Specialties.
In 1980, the first certification examination was administered by ABEM. Initially, ABEM outlined two different tracks a physician could follow to become qualified to take the certification examination in EM: (1) graduation from a residency program approved by the RRC, or (2) an interim practice track to "grandfather in" qualified physicians who had no opportunity to formally train in EM but had significant experience in EM practice. This track expired in June 1988 and now the sole means to become board-certified in EM is through an ABEM/AOBEM accredited EM residency. ABEM continuously strives to maintain the highest qualifying standards by requiring recertification every ten years and has recently implemented a continuous certification process requiring annual updates.5 These safeguards and training will ensure that the EP, who manages some of the most challenging and life-threatening situations encountered in medicine, be properly prepared and qualified.
Utilization of emergency services has steadily grown, showing an increase of 23% from 1992 to 2002.6 Public awareness of EM as a medical specialty, consumer expectations of rapid and comprehensive emergency care, difficulty accessing primary care, lack of medical insurance, and other factors are contributing to this increase in utilization.
EM as a Career
The EP's primary duty is to resuscitate and stabilize emergent patients and to see that all life-threatening causes of a patient's condition are considered. If all life-threatening causes cannot be adequately ruled-out in the ED due to resource or time constraints, the EP must see that the patient is admitted to the most appropriate service for further evaluation.
Because of the wide spectrum of patient presentations and acuity, the EP must be able to quickly recognize the sick patient, stabilize them with limited or no information and efficaciously evaluate them to reach a tentative diagnosis. All of this requires a quick mind, a decisive nature, a good fund of knowledge and interest in the breadth of medicine, excellent physical diagnostic skills, good manual dexterity, the deductive ability of a detective, and nerves of steel. It is also necessary to have special communication skills as the need frequently arises to establish rapport in a very short time with people under very stressful conditions. The EP must have an attitude of cooperation, as success in practice depends upon working effectively as a team member with members of your ED as well as physicians in other specialties.
Any student contemplating a career in EM should be willing to accept the benefits and limitations of the specialty. The variety in EM is an often-cited benefit as EP's treat patients of all ages and ethnicities with problems covering the breadth of medicine. Patient variety and workflow pace are totally unpredictable. Further, this is only one of very few medical specialties where you can experience the rewarding feeling (and adrenaline rush) of stabilizing a critically ill patient!
Practice Settings
Practice styles in EM can vary as widely as the settings in which they are located, and this flexibility is another benefit afforded to EP's. The majority of EP's practice in the community setting where a broad spectrum of patient encounters will range from minor colds to poisonings, sexual assaults, motor vehicle accidents, spouse and child abuse, and heart attacks. ED's in inner-city hospitals provide care for a large segment of society's indigent and uninsured patients who often present in extremis. Traumatic, weapon inflicted injuries are frequent. In the smaller, rural hospital, the ED may serve as the only resource for emergent and primary care in the community. This can offer the EP the opportunity to become a prominent community figure and know many of his or her patients on a first name basis.
The Job Market
There is currently a shortage of board-certified EP's which is expected to last for up to at least through the year 2030.4 In a recent survey, there were over 30% more positions than the number of EM residents graduating annually.7 As one might expect, graduating EM residents have very little difficulty securing employment. The salaries and benefits depend upon the setting and the type of practice. In 2003, the median salary for an EP was approximately $229,000, but the range of salaries stretches from the low $100,000's to above $300,000 depending on geographic location and practice environment.7 Almost all positions will offer some basic benefits which may include paid malpractice insurance premiums, retirement or pension plans, life insurance, and funded continued medical education. An EP may pick from many contractual arrangements and employment situations-- a salaried employee of a hospital, health maintenance organization, or academic institution; a partner in a small or large group of EP's; or an independent contractor. The cost of setting up a practice and overhead is low, enabling new residency graduates to begin earning competitive incomes immediately. This also allows EP's to move from one geographic location to another with little difficulty in securing a job in a new location.
Academic Emergency Medicine
If EM is an underdeveloped specialty, then academic EM is even more so. There are approximately 60 academic centers with a department of EM. There is a short supply and heavy demand for faculty to teach in these departments and at the residency programs. With the firm establishment of the specialty, many more medical schools are looking to fill their teaching programs with qualified faculty and eventually to create residency programs. The future of the specialty depends upon its ability to supply individuals who can establish a strong research base and train the clinicians of the future. The academic field is wide open and the ambitious EP can advance rapidly. Unfortunately, the salary for academics, similar to other specialties, falls short of the private practice potential, but the benefits and intrinsic rewards are great.
Research in this specialty can be as varied as the medical problems that present to the ED. EP's tend toward clinical research, as this is what usually attracts the physician to the specialty, but there is growing interest in basic science, educational, public health, and administrative research.
Opportunities Outside of the ED
An EP will usually work 40 to 60 hours a week, but there is ample opportunity for part-time or extra work. In addition to clinical duties, an EP may work closely with the hospital administration, the medical staff, or committees to build and maintain efficient emergency services. Equally important, a close working relationship with nursing and ancillary personnel may be fostered to provide the teamwork necessary in an emergent situation. Additionally, the EP may reach out into the community to establish and provide services for pre-hospital care and disaster planning. Community service may include teaching prevention and awareness, as well as bystander readiness to deal with cardiac arrest and other acute situations. On the other hand, there are many EP's who chose EM because it offered them the opportunity to pursue non-medical interests. They enjoy utilizing their free time for other activities and simply "punch the clock" and work their shifts when scheduled with minimal additional duties. There are practice environments in EM, which will allow you to be as involved or uninvolved as you would like.
Minorities and Women in EM
Minorities and women are well accepted in EM as EP's tend to have the ideals and standards of a younger society. Approximately 34% of residents in 2004-5 were women and 24% reported ethnicity other than white (not Hispanic).
Limitations
Emergency medicine is not a utopia and, like all medical specialties, it has its fair share of limitations. Most notably, at least 50% of all patient visits will be for minor, non-life threatening complaints. Patients may be seeking minor episodic care, second opinions, and possibly even emotional or socioeconomic support. The EP must treat these patients while simultaneously caring for more emergent patients. It becomes necessary to prioritize and often defer definitive diagnoses and treatment to more appropriate settings, which can limit the amount of follow-up information you obtain regarding the patients you see in the ED. Many patients with financial or personal problems present, because they have no alternate source of medical care. The EP cannot selectively evaluate patients but must see every person who presents to the ED, whether they are kind and cooperative or intoxicated and abusive. Often, the EP works as the only physician on duty unless the census of the department justifies more coverage. The shifts are physically demanding and often intense, ranging from 8 to 12 hours in length and often with little time to sit down or eat meals. In addition, the ED must have physician coverage 24 hours a day and 7 days a week. Thus, an EP's work schedule will vary throughout the month, including mornings, afternoons, and nights, constantly disrupting circadian rhythm. While the work schedule is predictable and flexible, it is by no means "regular." The EP will routinely work weekends and holidays and will miss occasional social and family affairs.
To avoid career mistakes or burnout, the student should have realistic expectations and consider all of the benefits and limitations mentioned above. An elective in EM can help to determine if the student really enjoys the milieu of the ED. Personality inventories such as the Myers-Briggs test, often administered by student affairs offices, may help determine if personality characteristics are suited to the lifestyle and practice. Not all medical schools have ED's staffed full-time by board-certified EP's. Therefore, it may be difficult for some students to examine first-hand the realities of practicing EM or to get realistic career advice regarding the specialty. The EM professional organizations listed in the footnotes can be a resource to help provide this needed service.
In fact, the Society of Academic Emergency Medicine (SAEM) has invested significant time and resources towards medical student advising. First, on the SAEM website (www.saem.org), there is a "Medical Student Section" which provides links to various articles about EM. Second, SAEM hosts an annual Medical Student Symposium, coinciding with the annual national meeting. In addition to hearing informative discussions, students will be able to interact with many residency program representatives at the residency fair. Third, a Virtual Advisors program allows students to be paired with an EP, who may provide additional guidance and advice via email or phone conversations This program is especially helpful for students whose medical schools are not yet affiliated with an EM residency program.
Residencies and Requirements
Residency training in EM is mandatory for any student considering a career in EM. Many students in the past have been advised to train in a "traditional" specialty and then cross over to the field, but since the practice track for board certification no longer exists, board certification in EM is not possible without completing an ABEM or AOBEM accredited EM residency. As more and more residency trained EP's enter the job market, it is unlikely that physicians trained in another specialty will be competitive for jobs in EM. The best reason to train in EM, however, is to become both competent and confident in caring for all the patients who come to the ED seeking emergency care. An EM residency will give you three to four years to acquire the knowledge base required to work in an ED while under the constant supervision and of a board-certified EP.
Residency training programs in EM may vary in both length and the year of postgraduate training in which they begin. Most programs are three years in length and begin with the first postgraduate year (PGY-1) immediately after medical school. There are four-year programs which can begin in the PGY-1 year or PGY-2 year, after one year of internship. All of the programs must meet the high standards set by the RRC. The first year of training usually consists of rotations covering all the major services with two to three months spent in the ED. During the second and third years, residents spend more time in the ED with the addition of critical care, trauma, and administrative rotations. When available, the fourth year of training usually entails more specialized rotations to learn the intricacies of toxicology, prehospital care, research, and administration as well as the opportunity to serve as "junior faculty" in the department, mentoring junior residents. This gradual introduction to graduated responsibility in the ED allows the resident to develop comprehensive medical knowledge and leadership skills. The RRC has been active in promulgating high standards for residency training including issues such as limiting resident work hours to a maximum of 12-hour shifts and 60 hours a week, structuring curricula, and providing appropriate full-time and on-site resident supervision.
EM residencies are among the most competitive across all specialties. Presently, there are more than 120 EM residency programs, which fill more than 1,332 entry-level (RRC-approved) positions annually through the National Residency Matching Program (NRMP) Match. In 2005, the fill rate for these RRC-approved residency positions in the US was 98.0%. The percentage of senior medical students from medical schools in the United States who secure a residency position in an EM residency has remained stable at 92-94%, indicating that the majority of students who want a residency in EM can secure one.9 For osteopathic medical students, there are an additional 95 residency positions in 26 EM residency programs approved by the American Osteopathic Association whose graduates are eligible for board certification by the AOBEM.
To be competitive for a residency position in EM, the student should have a record of solid academic performance in the pre-clinical years and clinical rotations in addition to strong letters of recommendation. Most residency programs will screen applicants for these qualities and use the interview to assess whether the applicant has the personal qualities needed to succeed in this field. Any evidence that the candidate can provide regarding a realistic understanding of, and commitment to, the specialty will enhance his or her chances of acquiring a residency position. Examples of commitment include (1) getting involved in a state or national EM organization, (2) joining an EM interest group, or (3) conducting EM research..
Opportunities exist to subspecialize within EM. Board-certified subspecialties include pediatric EM, medical toxicology, sports medicine, and undersea and hyperbaric medicine. Additional fellowships not leading to board certification exist in emergency medicine services, emergency ultrasound, aeromedicine, administration, teaching, research, and other fields. To date ABEM has been unsuccessful in its efforts to develop subspecialty certification for critical care medicine.
The Future
With a relatively short past to reflect upon, one might be hesitant to predict the future for EM. The recent acceleration in the pace of change in health care reform should cause anyone entering the field to carefully consider how the specialty will fit into the spectrum of health care providers. However, when one considers the energy and enthusiasm that EP's have typically shown in meeting their challenges, optimism must prevail. Emergency medicine, as a newcomer, has been the bell-weather for medicine in general. It has been the testing ground for the impact of the changing social conditions and governmental responses in our country and, thus far, EM has been a leader for innovation and positive change in meeting the current crises facing medicine.
As the EP workforce grows with time, there will be increased emphasis on creating a specialty more accommodating toward healthier lifestyles. Increasing numbers of younger physicians and women will play a vital role toward overcoming the specialty's attrition rate due to stress and job dissatisfaction as they introduce needed ideas to balance work with family, health and personal happiness. ED's will likely continue to be given priority hospital support as the they are seen as revenue-generating services for hospitals and important for hospital-community relations. To maximize this asset we will have to find ways of meeting the increased public demand for prompt and easily accessible emergency care. Expansion of emergency services to include intensive diagnostics, treatment and observation units, and "fast track" or urgent care centers is becoming more and more commonplace.
EM developed as a specialty by meeting the immediate needs of a vast and varied patient population unserved by other physicians largely due to the nature and timing of those medical needs. This specialty is comprised of one of the youngest and most dedicated groups of physicians who have become accustomed to pioneering new ideas. The future looks bright indeed for this growing specialty and for those who take on the challenge of becoming the next generation of EP's!
Joel M. Schofer, MD, LT MC USNR
Academic Chief Resident
Naval Medical Center, San Diego
jschofer@gmail.com
Christopher S. Russi, DO
Assistant Professor Emergency Medicine
Associate Residency Director
University of Iowa, Department of Emergency Medicine
christopher-russi@uiowa.edu
Louis S. Binder, MD
Associate Program Director and Director of Education
Department of Emergency Medicine,
MetroHealth Medical Center
Case Western Reserve University
lsbinder688@pol.net
References
- ACEP Resource Link
- ABEM Resource Link
- CDC ER Visit Statistics Resource Link
- Singer AJ, Singer AH, Thode HC. Reassessment of the emergency physician workforce demands. Acad Emerg Med (2004). 11:464-a.
- ABEM Resource Link
- National Hospital Ambulatory Medical Care Survey: 2002 Emergency Department Summary. Advance Data Number 340. 35 pp. (PHS) 2004-1250.
- Physicians in south central highest paid, survey says. ACEP News. October, 2003.
- Holliman CJ, Wuerz RC, Hirshberg AJ. Analysis of factors affecting U.S. emergency physician workforce projections. Acad Emerg Med (1997). 4:731-5.
- Binder LS. The 2005 NRMP match in mergency medicine. SAEM Newsletter
- Perina DG, Collier RE, Thomas HA, Korte RC, Reinhart MA. Report of the Task Force on Residency Training Information (2004-2005), American Board of Emergency Medicine. Annals of EM (2005). 45:532-547.
Residency programs, student rotations and faculty advisors, Contact: Society for Academic Emergency Medicine, 901 N. Washington Ave., Lansing, MI 48906, (517) 485-5484, FAX (517) 485-0801, saem@saem.org
Other Resources
- American Academy of Emergency Medicine, www.aaem.org
- American Academy of Emergency Medicine Resident & Student Association, www.aaemrsa.org
- American Board of Emergency Medicine, www.abem.org
- American College of Emergency Physicians, www.acep.org
- American College of Osteopathic Emergency Physicians, www.acoep.org
- Council of Emergency Medicine Residency Directors, www.cordem.org
- Emergency Medicine Resident's Association, www.emra.org
