- Email: [email protected]
Emergency care — an academic specialty?
Resuscitation (Casualty Surgeons Association Papers), 5, 197-204
Emergency care - an academic specialty? MILES IRVING Department of Surgery, University of Manchester, Hope Hospital, Salford M6 8HD, il. K.
All of us in the British Medical profession have watched with interest as the new discipline of Emergency Care, currently more usually known as ‘Accident and Emergency’, has emerged with increasing confidence. The sustained efforts of your professional body, the Casualty Surgeons Association, have resulted in the Department of Health, the Royal Colleges and the rest of the profession accepting that Emergency Care is a specialty in its own right, and it must be the source of much satisfaction for you to know that there are now around 150 consultants in the subject in the United Kingdom. The birth of a new specialty is both an exciting and a taxing time for its founder members. The task of establishing and maintaining high standards of care, and of developing relationships with other specialities, is difficult enough. Everyone, however, realises that it is also necessary to think about training and education and the securing of advances in the subject. It is in these areas that a University and Teaching Hospital contribution is necessary if real progress is to be made. I think it is a wise decision to think about such academic developments early in the formation of your specialty. The health of any specialty depends to a large extent upon the influence of vigorous and productive academic departments and they should be carefully nurtured. From these comments it is clear that I do not believe a question mark should have been placed after the title of this paper, for there is no reason why any specialty should not become an academic specialty if its practitioners decide to pursue truth and wisdom, and to advance and disseminate knowledge in their field. It thus follows that I shall not be discussing whether there should be an academic side to your subject, but only how such a side can be developed, and what it should be doing. The academic life Let me begin by considering the components of an academic clinician’s life. There are four cornerstones: clinical medicine, undergraduate and postgraduate teaching, research, and organization. It might be said that all of these are features of a National Health Service Text of a paper delivered at the Annual Symposium on Accidents and Emergencies at Windsor Postgraduate Medical Centre on Friday 3rd December, 1976. 197
198 M.IRVING consultant’s life, provided he is interested enough to devote time to them. This is, of course, true and such activities are not confined to academics. On the other hand it will be appreciated that one of the main problems in trying to encompass such a range of activities is lack of time occasioned by the sheer weight of clinical duties that a Health Service consultant is expected to bear. There is no doubt that if an effective academic side of your specialty is to be developed it must be staffed by doctors who have time to think about the subject unencumbered by excessive administrative and clinical duties. Such freedom is an expensive luxury and the only bodies in this country willing and able to pay for this luxury are the Universities and the Medical Research Council and the occasional charitable foundation. The bodies that sponsor research cannot be expected to support the other activities that should emanate from an academic department. Thus for all practical purposes, to obtain complete coverage of all aspects of the academic side, it is necessary to aim for University Departments of Emergency Care. It must be admitted that such departments will be a thorn in the flesh to many members of the specialty, constantly questioning and criticizing accepted practices and attitudes. If not carefully controlled this can easily degenerate into an ‘us and them’ situation which can lead to unpleasantness and lack of co-operation between academics and other clinical staff. The situation can be made worse if the clinical standards of the academic unit are obviously below those of the other units, for then, however correct the teaching emanating from the University Department, it will not be listened to by those who know their own standards of clinical care to be better. This very situation occurred in some of the older specialities when for a time it was considered that clinical skills were less important than research ability, with the result that some University Departments were not the centres of clinical excellence that they should have been. As a consequence their influence amongst their clinical colleagues waned. Despite the often excellent and relevant research emanting from their departments academics were accused of having neither the clinical ability nor the practical experience to understand the real problems of their Health Service colleagues. The damaging concept of the ‘ivory tower’ became well established and to this day taints relationships between town and gown. However, there is little doubt that this era of experimentalism in clinical academic units was necessary and its influence has been of considerable value. Now that there has been a swing back to the achievement of clinical excellence in University Departments the lessons of that era have not been forgotten and have been incorporated into the search for better and more rational ways of treating patients. It is important that from the outset new University Departments should benefit from the mistakes and experience of the older departments and, in the pursuit of academic excellence, should not forget the importance of clinical skills. I think it is essential for the University Department in any specialty to be a centre of excellence and it should be actively supported to become so by all members of that specialty. The department should be regarded by all as ‘our department’ and members of the specialty should feel able to use its facilities and be involved in all its activities. It should be regarded as normal for all trainees in the specialty to spend time in the department and when one of those trainees is regarded as having considerable academic potential, he should be encouraged to become a full-time faculty member. If, from the beginning, departmental policy is formulated in this way, all members of the specialty will feel positively involved and able to influence policy and training without conflicting with the independence that is so vital to academic life. Formed in this way a
CASUALTY SURGEONS ASSOCIATION PAPERS
199
University Department, whilst having all the necessary ambitions towards clinical excellence and research, is less likely to be elitist and isolationist and thus be more aware of the problems that affect National Health Service staff. Many academics would be surprised to find just how much they could learn from their colleagues in non-teaching hospitals and how much excellence and original thought there is amongst those who practise in these centres. In the grip of the current British financial crisis the existence of University Departments is vital if we are to maintain progress and standards of care which the public expect and know we can provide. The present is hardly the best time to form academic departments. Thus it has been a tragedy to see the medical profession, first through the National Health Service and now through the University Departments, forced to accept the concept of contractual hours in the shape of ‘units of medical time’. In the case of the University staff this arrangement has struck at the very heart of the academic’s life, in that there can be no hours of work in pursuit of the truth. Luckily the evidence is that junior academics and many Health Service staff are willing to defy the pressures to accept such unfortunate practices and one has to hope that through their continued goodwill the time will come when the retrograde activities can be reversed. These background comments are necessary for you to consider if in the future you are to spawn a successful academic side of your specialty. It is vital to have within it people of independent mind who will not be subjugated by the undesirable pressures that threaten academic life, and who will have the vision and maturity, coupled with the ability to work hard, to ensure that their departments act as powerhouses for improving standards, crystallizing problems and spreading new ideas for all members of your specialty. The Development
of University Departments of Emergency Care
I want now to consider how you as a group can develop an academic presence. Your specialty now has in the region of 150 consultants and recently the Joint Committee has started the task of assessing centres for the training of senior registrars in the specialty. Thus the time is ripe to make preparations for establishing one or more University Departments. As I see it, you have three main difficulties to face in the establishment of a viable academic side. First, and perhaps the least of the problems, the boundaries of your specialty are not well defined. Generally speaking such flexibility is an advantage, but it does give rise to the problem of selecting areas in which your academics will have especial expertise. It is likely that the pursuance of many such interests will inevitably overlap those of one’s specialist colleagues and could lead to conflict. Obviously, the development of special interests and expertise are vital to the academic. It is thus apparent that to avoid conflict these special interests will either have to be previously unexplored areas peculiar to Emergency Care or undertaken in collaboration with one’s specialist colleagues. The second difficulty is that your new specialty has yet to show whether it is viable. The number and calibre of the recruits to the new senior registrar posts will clearly indicate whether the subject has caught the imagination of young doctors and is attractive and challenging enough to have a secure future or whether it will become yet another shortage specialty. The answer to these questions in many ways lies in your own hands. If you
200
M. IRVING
ensure that only top-quality people are appointed to these training posts standards of care and training will rise, and it will be seen that Emergency Care is not ‘easy game’. As a result, human nature and professional pride will ensure that there will be competition for these posts. The final difficulty facing you is that few, if any, of you presently in the consultant posts, have actually trained for the specialty of Emergency Care. Many of you came into this specialty, not from choice, but because you did not obtain consultant posts in the specialty in which you originally trained. Thus the manner in which your specialty developed has been different from the manner in which most other specialities were formed. Emergency Care is in many ways a DHSS created specialty in response to pressure from the Casualty Surgeons Association and to a lesser extent political pressure, rather than a medical profession-created specialty. That is not to say the specialty is any less important than others, but the manner in which it has come into existence does create difficulties for the development of an academic side. I do not think you have amongst your ranks those who having obtained consultant status in an established specialty, and become interested in Emergency Medicine, have subsequently decided to concentrate upon their new interest to the exclusion of the old. This is, of course, how specialities such as neurosurgery, thoracic surgery and orthopaedics grew out of general surgery. I thus think it would be wrong for academic staff in Emergency Care to be appointed from within your own ranks at the present time. Where then should the staff come from? I think there are two alternatives. One is to invite an established authority on Emergency Care from overseas to come to the United Kingdom and start a department in a Teaching Hospital here. Such a person would be difficult to find in the English-speaking world; even in the United States the College of Emergency Physicians and The University Association for Emergency Services are at a developmental stage and do not appear as yet to have found their role, nor have they firmly established their research and training programmes. The second alternative is the more viable, and as I see it the only practical approach for your specialty at the present time. I believe that you should look for your future academics amongst the ranks of those who you accept as senior registrars on your training programmes. I have already commented on how important it is only to accept trainees of high calibre into your senior registrar grade. If you are to maintain impetus and allow them to show their ability and develop their potential then you must ensure that the training programmes are of the highest standard. Those suitable for, and interested in, the academic life will then reveal themselves during their training. The question then arises as to what you as a body can do to encourage interest in academic developments whilst your potential academics are in training. In the first instance your professional association, the Casualty Surgeons Association, should form a small but effective research group. The formation of such a group is vital not only for identifying research problems and mounting projects, but also for acting as a focus from which comments about scientific method can come at your meetings. It has been said that at times the lack of scientific method and a statistical approach in some of the papers presented at your meetings means that firmly stated conclusions are in fact open to alternative interpretations simply because the studies have been poorly designed or the correct questions have not been posed. The mounting of small but well constructed research projects by your research group will be of great value to all of you, but particularly to your new senior registrars. The
CASUALTYSURGEONSASSOCIATIONPAPERS
201
stimulation of critical thought amongst the new generation of Emergency Care Consultants is important and is vital to the potential academics amongst them. Needless to say, the results of such projects should be tested upon the forum of such established research groups as the Surgical Research Society and the Medical Research Society. The second way in which you can aid developments is for your better trainees to spend time in established academic departments and good research units in this country or overseas under the direction of experienced research workers. In this way they will learn the techniques of many aspects of research, such as epidemiology, laboratory work, statistics or the presentation of data. It is likely that these developments may be traumatic for some of you. Didactic teaching and ponderous pronouncements by the elder statesmen amongst you are likely to be challenged by questions requesting the data upon which such statements are made and the evidence of the controlled trial which the young academic will expect. In due course you should be able to encourage one or more of your trainees to enter the academic life committed to the study of Emergency Care. By this means the development of the departments will be an orderly planned process and not a haphazard affair. A friendly existing academic department should, initially, act as an umbrella to provide facilities and the protection that the new senior lecturer will need. One or two departments could be simultaneously started and carefully nurtured to ensure excellence. All this will, of course, require money. Ideally, the new departments should be funded entirely by the Universities, but as you will appreciate they are in no position to establish new departments at the present time, though certain Universities may agree to a subdepartment consisting of a senior lecturer and a small number of junior and supportive staff. It might be possible to overcome this unwillingness on the part of the Universities to become involved by negotiating for an endowed Chair and department. The pharmaceutical companies are unlikely to be interested; but the relationship between the Emergency Care Department and the insurance companies must be similar to the relationship between radiology and the makers of photographic materials, and the latter have endowed Chairs in Radiology. However, these propositions are subjects for protracted negotiation. What can be done to make a start? I think that as a group you have it within your power to finance research in Emergency Care in the near future. Legal reports are an added source of income for most consultants in Emergency Care. If each consultant in Emergency Care diverted 2 100 from his income from legal fees to a research fund over the next 12 months the money obtained would be more than sufficient to finance a research fellow and provide his expenses. If the money were given on a convenant basis it would ensure that when a University Department of Emergency Care was formed it would have at least one research fellow to its credit. Needless to say, the appropriate person to undertake the research fellowship would be one of the new senior registrars. Research This brings me to the question of research. Research is one of the cornerstones of academic life, providing tremendous stimulation to those associated with it. What do we mean by research? The easy answer is to say that it is the method by which new things are discovered. If this definition is adopted, then few will enjoy research or be satisfied by it,
202 M.IRVING for most of us are not destined to discover anything new. If, on the other hand, research is regarded as the answering of well-formulated questions about our subject, then all of us will achieve a result, even though as will usually be the case the answer to the question is negative. In any research-based discipline there are always further questions to be asked. For, as the sphere of knowledge expands, its interface with the unknown grows disproportionately. Research is not, of course, the sole prerogative of the academic. It can be undertaken by anyone, anywhere, if they have the time, the enthusiasm and knowledge of the techniques involved. Indeed many peripheral hospitals have the sort of cases and environment which demand study and yet are not available to the Teaching Hospitals in the city centres. Thus agricultural and mining emergencies, together with accidents on motorways, tend to go to suburban rather than urban hospitals. Consequently whereas the development of an academic department must by definition be in a University and its associated hospital, the carrying out of research should be fostered wherever there is interest and opportunity. It should be natural for those undertaking research projects outside the University Departments to look to these departments for support and advice. Before undertaking a research project a considerable amount of preparatory work is necessary if the outcome is to be successful. A great deal of thought should go into considering what question is to be asked. This should be followed by a detailed review of the relevant literature, using if necessary such aids as MEDLARS. When this has been completed a detailed statement of how the research is to be conducted is prepared, this statement commonly being call the protocol. The protocol should then be discussed in detail with a statistician and interested academics, or others who have an interest in the work to be undertaken. When the protocol has been agreed by all to be a reasonable approach to the problem it can be submitted for ethical approval and then shortly afterwards for funding. When funds have been obtained and any necessary staff employed a final check should be made to ensure that the system for recording the results is satisfactory and the study can begin. All this may seem an unnecessarily complex regimen, but it is worthwhile spending the time and effort and avoiding the disappointment of finding one’s results invalidated by simple omissions during the preparatory phase. Emergency Care would seem to contain many opportunities for research into not only the management of the acute situations, but also their cause, prevention, and sociological background. As a surgeon the most obvious field that springs to mind is that of trauma. In this country there is very little agreement on the severity of an injury, and scoring systems do not appear to have progressed as far as they have in the United States. Yet the very accuracy of inter-unit assessment, whether it be by audit, or the comparison of one unit’s results with another, or of one method of treatment with another, will depend upon agreement upon injury severity scores. A recent conference on roadside resuscitattion was held at Derby. How much of the discussion of the value of such treatment was based upon scientific assessment of comparable problems treated with and without the aid of roadside resuscitation? Here surely is a field in which consultants in Emergency Care can combine and undertake a study in order to agree on injury-severity scores that would be acceptable throughout the country. In the field of trauma this is a fundamental starting point and once such scoring has been agreed the way is open for meaningful discussion on all other aspects of trauma, including its management and prognosis.
CASUALTYSURGEONSASSOCIATIONPAPERS
203
These studies are, however, major undertakings which require considerable planning and are often best dealt with on a multicentre basis. More limited projects are themselves often of considerable interest and produce valuable information. Accident and Emergency Departments with their high patient turnover abound with problems that are, at present, often treated on an empirical basis, sometimes with expensive drugs. Thus bruising may be treated with enzyme preparations, wounds with prophylactic antibiotics and tenosynovitis by immobilization in plaster cases. All of these practices are much in need of a wellconducted controlled trial, the results of which may not only improve the quality of patient care, but may serve us all by reducing the country’s drug bill. I am sure that the medical and psychiatric cases presenting in your departments could be the subject of similar studies. Add to these the environmental, occupational and sociological aspects of your patients’ illnesses which demand factual analysis, and one would certainly not envisage a shortage of work for the new academics.
Education Finally, we must consider what many would regard as the most important of the academics’ activities, namely undergraduate and postgraduate education. I believe that the medical undergraduate should be introduced to Emergency Care in the first year with a simple firstaid course. This will enable him to be useful when as a medical student he is called upon to cope with emergency situations outside the hospital, and will also stimulate interest in his pre-clinical studies. During his early clinical years a period should be spent observing in the Accident and Emergency Department, usually as part of his medical and surgical clerkships. This should be supplemented by apprenticeship-type training in his final and houseofficer years. Postgraduate training is, of course, the responsibility of both the Royal Colleges and the Universities. I think that you are right to think about forming a Faculty of Emergency Care in association with one of the Colleges with your own training programmes and examina- _ tions, but I hope that you avoid the temptation to set up yet another College and another set of letters. After gaining the College Diploma, the M. D. should be the higher qualification to which the specialist in Emergency Care should be aspiring. I do not wish to go further into the question of higher specialist training for you are all well aware of the programmes that the Joint Committee has recommended and is in the process of establishing. However, I would like to reiterate how vital it is that these programmes be successful. Postgraduate training is a continuous and active process and the Accident and Emergency Department is in a unique position for exploring new methods of teaching. Lectures, tutorials and attendance at courses are well-tried methods of varying success. Other methods, however, need exploring. The continuous assessment of the department’s performance by some form of internal audit can be of value, not only in maintaining standards, but also as a positive educational exercise. The problems of ensuring that standards of treatment are maintained at times of day when the most senior members of staff are not available should be explored with use of microfiche instruction and flow charts now glorified with the name ‘algorithms’.
204 M. IRVING
Conclusion I trust that my comments will be of value to you in your deliberations about the development of an academic side to Emergency Care. They are delivered in all humility for I cannot pretend to have reached the standards that I have spoken about today. However, I do think that the aim of us all should be to strive constantly to attain and maintain such standards for the benefit of both our patients and our profession.
Emergency care - an academic specialty? MILES IRVING Department of Surgery, University of Manchester, Hope Hospital, Salford M6 8HD, il. K.
All of us in the British Medical profession have watched with interest as the new discipline of Emergency Care, currently more usually known as ‘Accident and Emergency’, has emerged with increasing confidence. The sustained efforts of your professional body, the Casualty Surgeons Association, have resulted in the Department of Health, the Royal Colleges and the rest of the profession accepting that Emergency Care is a specialty in its own right, and it must be the source of much satisfaction for you to know that there are now around 150 consultants in the subject in the United Kingdom. The birth of a new specialty is both an exciting and a taxing time for its founder members. The task of establishing and maintaining high standards of care, and of developing relationships with other specialities, is difficult enough. Everyone, however, realises that it is also necessary to think about training and education and the securing of advances in the subject. It is in these areas that a University and Teaching Hospital contribution is necessary if real progress is to be made. I think it is a wise decision to think about such academic developments early in the formation of your specialty. The health of any specialty depends to a large extent upon the influence of vigorous and productive academic departments and they should be carefully nurtured. From these comments it is clear that I do not believe a question mark should have been placed after the title of this paper, for there is no reason why any specialty should not become an academic specialty if its practitioners decide to pursue truth and wisdom, and to advance and disseminate knowledge in their field. It thus follows that I shall not be discussing whether there should be an academic side to your subject, but only how such a side can be developed, and what it should be doing. The academic life Let me begin by considering the components of an academic clinician’s life. There are four cornerstones: clinical medicine, undergraduate and postgraduate teaching, research, and organization. It might be said that all of these are features of a National Health Service Text of a paper delivered at the Annual Symposium on Accidents and Emergencies at Windsor Postgraduate Medical Centre on Friday 3rd December, 1976. 197
198 M.IRVING consultant’s life, provided he is interested enough to devote time to them. This is, of course, true and such activities are not confined to academics. On the other hand it will be appreciated that one of the main problems in trying to encompass such a range of activities is lack of time occasioned by the sheer weight of clinical duties that a Health Service consultant is expected to bear. There is no doubt that if an effective academic side of your specialty is to be developed it must be staffed by doctors who have time to think about the subject unencumbered by excessive administrative and clinical duties. Such freedom is an expensive luxury and the only bodies in this country willing and able to pay for this luxury are the Universities and the Medical Research Council and the occasional charitable foundation. The bodies that sponsor research cannot be expected to support the other activities that should emanate from an academic department. Thus for all practical purposes, to obtain complete coverage of all aspects of the academic side, it is necessary to aim for University Departments of Emergency Care. It must be admitted that such departments will be a thorn in the flesh to many members of the specialty, constantly questioning and criticizing accepted practices and attitudes. If not carefully controlled this can easily degenerate into an ‘us and them’ situation which can lead to unpleasantness and lack of co-operation between academics and other clinical staff. The situation can be made worse if the clinical standards of the academic unit are obviously below those of the other units, for then, however correct the teaching emanating from the University Department, it will not be listened to by those who know their own standards of clinical care to be better. This very situation occurred in some of the older specialities when for a time it was considered that clinical skills were less important than research ability, with the result that some University Departments were not the centres of clinical excellence that they should have been. As a consequence their influence amongst their clinical colleagues waned. Despite the often excellent and relevant research emanting from their departments academics were accused of having neither the clinical ability nor the practical experience to understand the real problems of their Health Service colleagues. The damaging concept of the ‘ivory tower’ became well established and to this day taints relationships between town and gown. However, there is little doubt that this era of experimentalism in clinical academic units was necessary and its influence has been of considerable value. Now that there has been a swing back to the achievement of clinical excellence in University Departments the lessons of that era have not been forgotten and have been incorporated into the search for better and more rational ways of treating patients. It is important that from the outset new University Departments should benefit from the mistakes and experience of the older departments and, in the pursuit of academic excellence, should not forget the importance of clinical skills. I think it is essential for the University Department in any specialty to be a centre of excellence and it should be actively supported to become so by all members of that specialty. The department should be regarded by all as ‘our department’ and members of the specialty should feel able to use its facilities and be involved in all its activities. It should be regarded as normal for all trainees in the specialty to spend time in the department and when one of those trainees is regarded as having considerable academic potential, he should be encouraged to become a full-time faculty member. If, from the beginning, departmental policy is formulated in this way, all members of the specialty will feel positively involved and able to influence policy and training without conflicting with the independence that is so vital to academic life. Formed in this way a
CASUALTY SURGEONS ASSOCIATION PAPERS
199
University Department, whilst having all the necessary ambitions towards clinical excellence and research, is less likely to be elitist and isolationist and thus be more aware of the problems that affect National Health Service staff. Many academics would be surprised to find just how much they could learn from their colleagues in non-teaching hospitals and how much excellence and original thought there is amongst those who practise in these centres. In the grip of the current British financial crisis the existence of University Departments is vital if we are to maintain progress and standards of care which the public expect and know we can provide. The present is hardly the best time to form academic departments. Thus it has been a tragedy to see the medical profession, first through the National Health Service and now through the University Departments, forced to accept the concept of contractual hours in the shape of ‘units of medical time’. In the case of the University staff this arrangement has struck at the very heart of the academic’s life, in that there can be no hours of work in pursuit of the truth. Luckily the evidence is that junior academics and many Health Service staff are willing to defy the pressures to accept such unfortunate practices and one has to hope that through their continued goodwill the time will come when the retrograde activities can be reversed. These background comments are necessary for you to consider if in the future you are to spawn a successful academic side of your specialty. It is vital to have within it people of independent mind who will not be subjugated by the undesirable pressures that threaten academic life, and who will have the vision and maturity, coupled with the ability to work hard, to ensure that their departments act as powerhouses for improving standards, crystallizing problems and spreading new ideas for all members of your specialty. The Development
of University Departments of Emergency Care
I want now to consider how you as a group can develop an academic presence. Your specialty now has in the region of 150 consultants and recently the Joint Committee has started the task of assessing centres for the training of senior registrars in the specialty. Thus the time is ripe to make preparations for establishing one or more University Departments. As I see it, you have three main difficulties to face in the establishment of a viable academic side. First, and perhaps the least of the problems, the boundaries of your specialty are not well defined. Generally speaking such flexibility is an advantage, but it does give rise to the problem of selecting areas in which your academics will have especial expertise. It is likely that the pursuance of many such interests will inevitably overlap those of one’s specialist colleagues and could lead to conflict. Obviously, the development of special interests and expertise are vital to the academic. It is thus apparent that to avoid conflict these special interests will either have to be previously unexplored areas peculiar to Emergency Care or undertaken in collaboration with one’s specialist colleagues. The second difficulty is that your new specialty has yet to show whether it is viable. The number and calibre of the recruits to the new senior registrar posts will clearly indicate whether the subject has caught the imagination of young doctors and is attractive and challenging enough to have a secure future or whether it will become yet another shortage specialty. The answer to these questions in many ways lies in your own hands. If you
200
M. IRVING
ensure that only top-quality people are appointed to these training posts standards of care and training will rise, and it will be seen that Emergency Care is not ‘easy game’. As a result, human nature and professional pride will ensure that there will be competition for these posts. The final difficulty facing you is that few, if any, of you presently in the consultant posts, have actually trained for the specialty of Emergency Care. Many of you came into this specialty, not from choice, but because you did not obtain consultant posts in the specialty in which you originally trained. Thus the manner in which your specialty developed has been different from the manner in which most other specialities were formed. Emergency Care is in many ways a DHSS created specialty in response to pressure from the Casualty Surgeons Association and to a lesser extent political pressure, rather than a medical profession-created specialty. That is not to say the specialty is any less important than others, but the manner in which it has come into existence does create difficulties for the development of an academic side. I do not think you have amongst your ranks those who having obtained consultant status in an established specialty, and become interested in Emergency Medicine, have subsequently decided to concentrate upon their new interest to the exclusion of the old. This is, of course, how specialities such as neurosurgery, thoracic surgery and orthopaedics grew out of general surgery. I thus think it would be wrong for academic staff in Emergency Care to be appointed from within your own ranks at the present time. Where then should the staff come from? I think there are two alternatives. One is to invite an established authority on Emergency Care from overseas to come to the United Kingdom and start a department in a Teaching Hospital here. Such a person would be difficult to find in the English-speaking world; even in the United States the College of Emergency Physicians and The University Association for Emergency Services are at a developmental stage and do not appear as yet to have found their role, nor have they firmly established their research and training programmes. The second alternative is the more viable, and as I see it the only practical approach for your specialty at the present time. I believe that you should look for your future academics amongst the ranks of those who you accept as senior registrars on your training programmes. I have already commented on how important it is only to accept trainees of high calibre into your senior registrar grade. If you are to maintain impetus and allow them to show their ability and develop their potential then you must ensure that the training programmes are of the highest standard. Those suitable for, and interested in, the academic life will then reveal themselves during their training. The question then arises as to what you as a body can do to encourage interest in academic developments whilst your potential academics are in training. In the first instance your professional association, the Casualty Surgeons Association, should form a small but effective research group. The formation of such a group is vital not only for identifying research problems and mounting projects, but also for acting as a focus from which comments about scientific method can come at your meetings. It has been said that at times the lack of scientific method and a statistical approach in some of the papers presented at your meetings means that firmly stated conclusions are in fact open to alternative interpretations simply because the studies have been poorly designed or the correct questions have not been posed. The mounting of small but well constructed research projects by your research group will be of great value to all of you, but particularly to your new senior registrars. The
CASUALTYSURGEONSASSOCIATIONPAPERS
201
stimulation of critical thought amongst the new generation of Emergency Care Consultants is important and is vital to the potential academics amongst them. Needless to say, the results of such projects should be tested upon the forum of such established research groups as the Surgical Research Society and the Medical Research Society. The second way in which you can aid developments is for your better trainees to spend time in established academic departments and good research units in this country or overseas under the direction of experienced research workers. In this way they will learn the techniques of many aspects of research, such as epidemiology, laboratory work, statistics or the presentation of data. It is likely that these developments may be traumatic for some of you. Didactic teaching and ponderous pronouncements by the elder statesmen amongst you are likely to be challenged by questions requesting the data upon which such statements are made and the evidence of the controlled trial which the young academic will expect. In due course you should be able to encourage one or more of your trainees to enter the academic life committed to the study of Emergency Care. By this means the development of the departments will be an orderly planned process and not a haphazard affair. A friendly existing academic department should, initially, act as an umbrella to provide facilities and the protection that the new senior lecturer will need. One or two departments could be simultaneously started and carefully nurtured to ensure excellence. All this will, of course, require money. Ideally, the new departments should be funded entirely by the Universities, but as you will appreciate they are in no position to establish new departments at the present time, though certain Universities may agree to a subdepartment consisting of a senior lecturer and a small number of junior and supportive staff. It might be possible to overcome this unwillingness on the part of the Universities to become involved by negotiating for an endowed Chair and department. The pharmaceutical companies are unlikely to be interested; but the relationship between the Emergency Care Department and the insurance companies must be similar to the relationship between radiology and the makers of photographic materials, and the latter have endowed Chairs in Radiology. However, these propositions are subjects for protracted negotiation. What can be done to make a start? I think that as a group you have it within your power to finance research in Emergency Care in the near future. Legal reports are an added source of income for most consultants in Emergency Care. If each consultant in Emergency Care diverted 2 100 from his income from legal fees to a research fund over the next 12 months the money obtained would be more than sufficient to finance a research fellow and provide his expenses. If the money were given on a convenant basis it would ensure that when a University Department of Emergency Care was formed it would have at least one research fellow to its credit. Needless to say, the appropriate person to undertake the research fellowship would be one of the new senior registrars. Research This brings me to the question of research. Research is one of the cornerstones of academic life, providing tremendous stimulation to those associated with it. What do we mean by research? The easy answer is to say that it is the method by which new things are discovered. If this definition is adopted, then few will enjoy research or be satisfied by it,
202 M.IRVING for most of us are not destined to discover anything new. If, on the other hand, research is regarded as the answering of well-formulated questions about our subject, then all of us will achieve a result, even though as will usually be the case the answer to the question is negative. In any research-based discipline there are always further questions to be asked. For, as the sphere of knowledge expands, its interface with the unknown grows disproportionately. Research is not, of course, the sole prerogative of the academic. It can be undertaken by anyone, anywhere, if they have the time, the enthusiasm and knowledge of the techniques involved. Indeed many peripheral hospitals have the sort of cases and environment which demand study and yet are not available to the Teaching Hospitals in the city centres. Thus agricultural and mining emergencies, together with accidents on motorways, tend to go to suburban rather than urban hospitals. Consequently whereas the development of an academic department must by definition be in a University and its associated hospital, the carrying out of research should be fostered wherever there is interest and opportunity. It should be natural for those undertaking research projects outside the University Departments to look to these departments for support and advice. Before undertaking a research project a considerable amount of preparatory work is necessary if the outcome is to be successful. A great deal of thought should go into considering what question is to be asked. This should be followed by a detailed review of the relevant literature, using if necessary such aids as MEDLARS. When this has been completed a detailed statement of how the research is to be conducted is prepared, this statement commonly being call the protocol. The protocol should then be discussed in detail with a statistician and interested academics, or others who have an interest in the work to be undertaken. When the protocol has been agreed by all to be a reasonable approach to the problem it can be submitted for ethical approval and then shortly afterwards for funding. When funds have been obtained and any necessary staff employed a final check should be made to ensure that the system for recording the results is satisfactory and the study can begin. All this may seem an unnecessarily complex regimen, but it is worthwhile spending the time and effort and avoiding the disappointment of finding one’s results invalidated by simple omissions during the preparatory phase. Emergency Care would seem to contain many opportunities for research into not only the management of the acute situations, but also their cause, prevention, and sociological background. As a surgeon the most obvious field that springs to mind is that of trauma. In this country there is very little agreement on the severity of an injury, and scoring systems do not appear to have progressed as far as they have in the United States. Yet the very accuracy of inter-unit assessment, whether it be by audit, or the comparison of one unit’s results with another, or of one method of treatment with another, will depend upon agreement upon injury severity scores. A recent conference on roadside resuscitattion was held at Derby. How much of the discussion of the value of such treatment was based upon scientific assessment of comparable problems treated with and without the aid of roadside resuscitation? Here surely is a field in which consultants in Emergency Care can combine and undertake a study in order to agree on injury-severity scores that would be acceptable throughout the country. In the field of trauma this is a fundamental starting point and once such scoring has been agreed the way is open for meaningful discussion on all other aspects of trauma, including its management and prognosis.
CASUALTYSURGEONSASSOCIATIONPAPERS
203
These studies are, however, major undertakings which require considerable planning and are often best dealt with on a multicentre basis. More limited projects are themselves often of considerable interest and produce valuable information. Accident and Emergency Departments with their high patient turnover abound with problems that are, at present, often treated on an empirical basis, sometimes with expensive drugs. Thus bruising may be treated with enzyme preparations, wounds with prophylactic antibiotics and tenosynovitis by immobilization in plaster cases. All of these practices are much in need of a wellconducted controlled trial, the results of which may not only improve the quality of patient care, but may serve us all by reducing the country’s drug bill. I am sure that the medical and psychiatric cases presenting in your departments could be the subject of similar studies. Add to these the environmental, occupational and sociological aspects of your patients’ illnesses which demand factual analysis, and one would certainly not envisage a shortage of work for the new academics.
Education Finally, we must consider what many would regard as the most important of the academics’ activities, namely undergraduate and postgraduate education. I believe that the medical undergraduate should be introduced to Emergency Care in the first year with a simple firstaid course. This will enable him to be useful when as a medical student he is called upon to cope with emergency situations outside the hospital, and will also stimulate interest in his pre-clinical studies. During his early clinical years a period should be spent observing in the Accident and Emergency Department, usually as part of his medical and surgical clerkships. This should be supplemented by apprenticeship-type training in his final and houseofficer years. Postgraduate training is, of course, the responsibility of both the Royal Colleges and the Universities. I think that you are right to think about forming a Faculty of Emergency Care in association with one of the Colleges with your own training programmes and examina- _ tions, but I hope that you avoid the temptation to set up yet another College and another set of letters. After gaining the College Diploma, the M. D. should be the higher qualification to which the specialist in Emergency Care should be aspiring. I do not wish to go further into the question of higher specialist training for you are all well aware of the programmes that the Joint Committee has recommended and is in the process of establishing. However, I would like to reiterate how vital it is that these programmes be successful. Postgraduate training is a continuous and active process and the Accident and Emergency Department is in a unique position for exploring new methods of teaching. Lectures, tutorials and attendance at courses are well-tried methods of varying success. Other methods, however, need exploring. The continuous assessment of the department’s performance by some form of internal audit can be of value, not only in maintaining standards, but also as a positive educational exercise. The problems of ensuring that standards of treatment are maintained at times of day when the most senior members of staff are not available should be explored with use of microfiche instruction and flow charts now glorified with the name ‘algorithms’.
204 M. IRVING
Conclusion I trust that my comments will be of value to you in your deliberations about the development of an academic side to Emergency Care. They are delivered in all humility for I cannot pretend to have reached the standards that I have spoken about today. However, I do think that the aim of us all should be to strive constantly to attain and maintain such standards for the benefit of both our patients and our profession.