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The “Fad” Turns 40: ACEP Celebrates 4 Decades of Service
The “Fad” Turns 40: ACEP Celebrates 4 Decades of Service by GEORGE FLYNN Special Contributor to Annals News & Perspective
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he founders’ blood, in fact, flows through your vessels – through every emergency physician’s vessels. Their heart has been transplanted into your heart. Don’t let them down. Keep the faith with those who kept the promise.” – Ronald L. Krome The “fad” of emergency medicine as a specialty turns 40 this year. The keystone anniversary of the 1968 birth of the American College of Emergency Physicians (ACEP) arrives in ways that founders would not have recognized in this era of modern medicine. Ronald L. Krome, MD, who retired as a Wayne State emergency medicine professor in 2004 after 43 years as a physician, was one of the early pioneers to practice emergency medicine full time. He recalled the earlier era, when a surgeon colleague asked a popular question of the time: Why was Krome interested in such a fad as emergency medicine? He reflected on the question, then thought of when they would both be at the “pearly gates” facing St. Peter. The surgeon might offer up a list that he’d “done ‘X’ number of gall bladder removals, repaired hernias and ulcers” and so on, Dr. Krome wrote. In contrast, Dr. Krome said he could tell the saint something else: “I have changed the face of medicine for all time.” Volume , . : October
ACEP’s mark comes for an organization that has grown from 8 charter members to more than 26,000 of the 40,000 US emergency physicians. From a fledgling organization fighting for the peer respect that would make it the 23rd recognized medical specialty, leaders say ACEP is now a dominant organization in American medicine. “The world is our oyster,” ACEP Executive Director Dean Wilkerson said in describing the accomplishments and the work ahead for the organization. “We have the capability, and we have the challenges, on all sides.”
ACEP TAKES THE POLITICAL STAGE
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hose sides show themselves in internal career needs as well as external issues that increasingly put ACEP in the center of some of the most controversial concerns for the future of medical care. There are academics, research, subspecialties such as pediatrics, EMS development and more. International and disaster emergency medicine are 2 of the newest focuses. Hot-button issues are in the political and public arenas, such as hospital boarding or crowding, universal health care and fundamental conflicts with insurers and employee health plans. “I think we are at the crossroads, and are the safety net, for the entire health care system,” Wilkerson said. “As an organization it becomes challenging, with a limited budget and staff and leadership,
to, you know, ‘put the peanut butter on all those pieces of bread.’” ACEP today has 29 sections and 25plus committees concentrated on specific areas of emergency medicine. Spin-off organizations are active in the academic and research fields; 53 chapters cover every state, Puerto Rico and Washington D.C. The nation’s capital includes an advocacy office as part of the 100 staff members serving ACEP. Judd Hollander, MD, the 2007-2008 president of the Society of Academic Emergency Medicine (SAEM), said ACEP has been effective in part because it has used that broad base in coordinating and supporting efforts with other organizations to benefit research and the field in general. “It has become very collaborative and really synergistic,” Dr. Hollander said. “I think the collaborative growth of the societies together has done the most to advance mission care.” The immense ACEP membership infrastructure is dwarfed only by the size of the ultimate clients–some 119 million emergency patients treated annually in the US. Brian Zink, MD, a physician, author and historian on the emergence of the specialty, said it is unique from other disciplines because the founders created it primarily in response to the needs of patients rather than physicians. “Emergency medicine arose out of almost a social phenomenon–it was patients driving them,” Dr. Zink said. “It is really the only medical field or specialty that has arisen out of a socio-political process of patients presenting for care because they didn’t have other places to go.” Medical fields overall have made significant strides in recent decades, Dr. Zink said, although emergency medicine has been the quantum leap. “The combination of the societal demand, and the patients and medicine, have really created this field, and this improved care,” Dr. Zink said. “If you look at what has changed in the last 30 Annals of Emergency Medicine 373
years in American medicine, you can make a very strong argument that the thing that is most different, and has resulted in the most progress, is the care of sick and injured people by emergency physicians.” Arthur Kellermann, MD, MPH, a past member of the ACEP Board of Directors, joined in the salutes while cautioning about the immense work ahead for the organization and emergency medicine. “We are also the front line of many of the ills and flaws of the current system,” Dr. Kellermann said. “Some 47 million Americans without health insurance; more and more doctors unwilling to take emergency or trauma calls; tremendous financial and operational constraints are being placed on the system, and there is more and more second-guessing by insurance companies and the medical-legal community and others.” Still, he said, “When you consider how far EM has come in 40 years, it has got to be one of the most astonishing stories in the last 100 years of American medical history.” “This specialty came out of nowhere, established itself, developed a political and scientific identity, and has had a profound impact on health care in this country,” Dr. Kellermann concluded. As late as a half-century ago, emergency medicine languished largely as a merely tolerated stepchild of the American health care system.
THE HISTORY OF THE “PIT”
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lenn Hamilton, MD, a past president of SAEM and emergency medicine chair at Wright State University, wrote a historical summary of the situation at many emergency departments (EDs) in the late 1960s. “Unsupervised activities that would never be allowed to occur on the wards happened daily in the ED with rarely a second thought or concern by academic chairs or hospital leadership,” he said. “The ‘pit’ was another world entirely, a distant place to be visited as little as possible.” Specialists’ only expectation was that physicians in the ED could do nothing, or “nearly anything with a little telephone guidance,” Dr. Hamilton wrote. Academics and specialists both viewed the assignment “as where you started or
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ended your practice, or a place to be exiled if you were impaired or incompetent.” Hamilton told of the summer of 1970, when he clerked for 2 emergency physicians–75 and 78 years old–in a small northern Michigan ED. For about $10 an hour, they alternated 12-hour shifts and were on call. The 2 “were wonderfully practical, welcoming, and had 100 years of medical practice between them. When in doubt, they simply did whatever book they had said, or went with their ‘gut.’ That was evidence enough,” Dr. Hamilton wrote. When the movement for change began, “It was as if a new life form was trying to arise from the most neglected part of the hospital–the unspeakable or laughable ‘pit,’” Dr. Hamilton said. “This growth was viewed by many in academic medical centers as similar to a malignancy, something requiring surgical removal or irradiation, something to be eradicated.” Internal hospital politics didn’t prevail in derailing the effort, for a couple of basic reasons. Historians cite the remarkable resiliency of the maverick emergency physicians, who knew that reform was essential. More support emerged on the public forefront. The Vietnam War had produced major advances in trauma care, and illustrated a clear need for training and expertise in emergency care. That emphasis and awareness returned home from the battlefields. An increasingly mobile populace, and modernization of medicine, were relegating house calls to the history books, and separating patients from the customary source of treatment at family physicians’ offices. Insurance and its impact had also expanded to health care, in many cases with coverage for treatment in hospitals but not physician offices. The reported number of emergency visits had already jumped fourfold from 1940 to 1955. Some hospitals in urban areas had been slowly awakening to the needs. James Mills Jr., MD, who would go on to become president of the future ACEP, upgraded ED staffing at his Alexandria hospital. It had relied on physicians splitting duties between their primary work and the ED. Mills, in part to have more time with his own family, left his family
practice and became part of a 4-physician team that served full-time in the ED. Other hospitals realized they could have models based on that “Alexandria Plan,” or the alternative Pontiac Plan. It was developed by the Michigan general hospital of that name, which assigned rotations for more than 20 doctors for monthly stints of up to 32 hours in the ED. Public sentiments were jolted by the 1966 National Research Council/National Academy of Sciences report, “Accidental Death and Disability: The Neglected Disease of Modern Society.” It decried the lack of EMS standards, saying the nation was “insensitive to the magnitude of the problem.” The numbers turned the heads of the public: In the previous year, accident injuries had killed 107,000 Americans. The report was credited with prompting the first standards for emergency care, and focusing attention on ED deficiencies and staffing as well. Among the recommendations were licensing and regular inspection of ED facilities. Ambulances– in some places, they had been little more than repainted hearses owned by funeral homes– and their personnel were facing regulations and training requirements for the first time.
“ANYWHERE, ANYTHING, ANYTIME”
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utside commentaries were still secondary to the internal influences that began building within the medical profession. Dr. Zink, in his definitive 2006 book, Anyone, Anything, Anytime – A History of Emergency Medicine, captured the unique characters that began stepping forward to carve a genuine specialty from the chaotic ED conditions. These rebels became known as much for what they weren’t as for what they were. Zink said most of them had a modest Midwest upbringing rather than Ivy League pedigree, “and they were not plugged into the medical elite in this country. They were starting something new on a grassroots basis.” Typifying this kind of revolutionary was the man most credited with creating the specialty. John Wiegenstein, MD, was born in a cabin in Missouri; he had dabbled in pursuits toward careers as an Volume , . : October
engineer in the automobile industry, then aviator, and even spent time in a seminary before settling on medicine. Research by Dr. Zink, Dr. Hamilton and others showed the struggle Dr. Wiegenstein had in just getting his medical degree in 1960. His medical school banned students from other jobs, but he moonlighted at night as an information desk clerk at University Hospital to support his wife and children. He laughed about having to “duck” when any of his professors passed the desk. Humor was darker during his ED shifts at St. Lawrence Hospital in Lansing, MI, as he recounted the series of drunks and drifters–the doctors, not patients– on hand there. He once was relieved by a dermatologist who walked in and announced he was going to get some sleep: “Call me if a life-threatening rash comes in,” that physician said.
A LIFE SAVED
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is first year at St. Lawrence, he was in the hospital when a nurse alerted him that a father was in the parking lot with a baby boy “who looks dead.” Dr. Wiegenstein quickly identified throat blockage from an epiglottitis. He knew nothing about tracheostomies for children– he would perform his first on that black-and-blue infant. Dr. Wiegenstein found that he actually enjoyed being awakened at early hours and rushing into the challenges of critical trauma care. In whatever spare time he could muster, he began sitting in on seminars and courses for surgery and other specialties, in a realization of the importance of the “golden hour” for trauma care. That drive also put him in contact with more and more physicians who shared his concerns about the haphazard approach to emergency medicine. Dr. Zink said this pioneer blended a modest personality with keen sense of mission. “Very much driven by values, he kept pursuing in a very determined way what he saw needed to be done,” Dr. Zink said, “which was to form a strong organization in order to propel good emergency care to our patients.” “John is responsible for mentoring many within the emergency medicine community, and those individuals then
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helped train me and thousands of other emergency care providers across the country,” Robert Prodinger, DO, wrote in 2004 in the Medicine at Michigan publication of the University of Michigan. “. . . Millions of patients now receive safe, quality emergency health care due to the work of John and all those who worked with him, and those who have followed. The legacy John leaves behind is enormous, and enormously inspiring.” Dr. Prodinger knew personally of Dr. Wiegenstein’s commitment. About 18 years ago, he was an orderly who searched out Dr. Wiegenstein when he was chief of emergency medicine at Ingham County Medical Center. Dr. Prodinger explained to the doctor they had met much earlier. He lowered his collar and displayed a small scar, the remnant of a tracheostomy. The doctor had performed it on him in his infancy, when his father had rushed him to the Lansing hospital. “I would not be where I am today in my career without the work of John Wiegenstein,” Dr. Prodinger wrote. “I will always be thankful for his foresight and vision, and his ability to undauntedly apply his skills to saving my life when I was a child.”
A SPECIALTY BORN
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ack in August 1968 in Lansing, Dr.Wiegenstein had delivered the birth of ACEP. He and 7 other physicians met at a Holiday Inn to found the organization with one page of bylaws, an impressive name–and little else but a determination to succeed. “We had an awful fight from the other specialties,” Dr. Wiegenstein recalled in 2003 about the 20-year effort for emergency medicine. “Surgeons thought we were invading their turf. The internists thought they might lose their resident training opportunities. People didn’t believe that one specialty could encompass all the lifesaving techniques you need as an emergency room doctor.” The longest period of calm for ACEP may have been counted in minutes, during the opening moments of the meeting to organize it. Physician Richard Lingenfelter, MD, took offense at allowing membership to anyone who voluntarily devoted a significant amount of their practice to surgery or emergency medi-
cine. He objected to including osteopaths, and parted ways with the organization. Three months later, ACEP more than tripled its membership–to 30 doctors. The group learned that another physician, Reinald Leidelmeyer, MD, had already planned to host a meeting of emergency physicians at a Marriott in Arlington, VA. At that session, Dr. Wiegenstein led the effort to get them to embrace ACEP. The organization’s first Scientific Assembly followed in Denver. Dr. Wiegenstein tapped the American Medical Association for more help in developing the educational seminars and related programs to begin establishing emergency medicine as a specialty. Expansion was rapid. The second Scientific Assembly, held in Las Vegas, drew 600 physicians and offered well-defined programs. In 1970, the University of Cincinnati launched the first emergency medicine residency program, although ACEP failed in an effort to get approval from the AMA Council on Medical Education for formal training. Dr. Zink said a landmark event was the so-called “Blue Book” meeting in 1973; ACEP had to fully document the basis for emergency medicine and residency programs and specialist training. “They had to convince all the other people from all the other specialties, and from government and the big medical organizations that there was a clear need for the specialty,” he said. “It legitimized the specialty in the kind of forum that had everyone together, which really hadn’t occurred up until that point.” The AMA granted the request for a provisional section on emergency medicine in 1973, which gave ACEP entry into the association’s House of Delegates. Two years later, that Section Council of Emergency Medicine became a permanent part of the AMA structure. ACEP led the way in creating the American Board of Emergency Medicine in 1976, which had a proposed certifying examination.
DOOR CLOSED, WINDOW OPENED
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owever, the door slammed shut on their hopes in 1977. The American Board of Medical Specialties (ABMS) jolted the movement by defeatAnnals of Emergency Medicine 375
Science and the Specialty Every specialty needs a journal in which to publish peer reviewed research, and ACEP (The Journal of the American College of Emergency Physicians, or JACEP) printed its first issue in January 1972. It contained absolutely no original science (not even a case report), and the editors stated “there will be a place for almost any conceivable contribution.” Educational content consisted of synopses of review lectures given at CME courses. The single largest content area was classified ads for jobs available (8 pages), with typical full time jobs requiring 40 or more hours of clinical, paying about $30,000 a year, and looking for applicants of any or no specialty who “can work hard and fast.” How far the journal and the specialty have come. We have changed our name (from JACEP to Annals of Emergency Medicine), and our issues are full of science rigorous enough that case reports have a very hard time getting accepted. Now Annals is the largest and most prestigious emergency medicine journal, and ranks in the top 12% of all scientific journals of any kind in impact factor and number of citations. Its stories get extensive coverage in the lay media, and its Web page received about 900,000 page views in the most recent year. Its timeliness and quality of peer review is among the best. All of this helps us fulfill our role of being the scientific voice of emergency medicine, publishing the data that will change clinical practice and will be used by our leadership to change health policy. Thanks to all the researchers, reviewers, and editors whose dedication over the years has made this come to pass. Although we are still having to work hard and fast. Michael L. Callaham, MD Editor in Chief
ing a measure to make emergency medicine a specialty. Dr. Zink, in his history of ACEP, described the inner turmoil after losing 376 Annals of Emergency Medicine
the ABMS vote. There were calls to abandon the ABMS efforts and try to establish a separate board. Dr. Wiegenstein and some College leaders instead pressed for a compromise that would give the emergency medicine conjoint board representation through other specialty boards at ABMS. “He soothed those who were reckless and implored those who were timid,” Dr. Zink said of Dr. Wiegenstein’s approach. “He was the leader emergency medicine needed at this stage of its development.” One long-time nemesis was physician Oscar Hampton, MD, who chaired the American College of Surgeons’ Committee on Trauma when ACEP was trying for Section Council status with AMA in the early 1970s. Dr. Zink’s research told of Dr. Wiegenstein’s gambit during a key hearing on the issue, when he and Dr. Hampton were to face off in front of some of the most influential forces in medicine at the time. As the issue was coming up on the agenda, Dr. Wiegenstein slipped out of the meeting so Dr. Hampton would have to go first. Then he listened just outside as the surgeon decried the idea of a new specialty identified by nothing more than the room– emergency room–where they practiced. When Dr. Hampton finished, Dr. Wiegenstein gave his spirited defense of the movement. He even raised another suggestion: Shouldn’t surgeons themselves also be known by their room, as “operating room doctors”? The ACEP leader went on a frantic lobbying pursuit of officials of other boards for their required approval of the arrangement. Plagued by viral hepatitis at one point, he recovered. So did ACEP. In 1979, ABMS recognized emergency medicine as a medical specialty.
A LEADER LOST
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r. Wiegenstein’s dedication to developing emergency medicine would lead to top positions and honors from several medical societies and associations in future years. He retired in 2001 to the good life at the Eden on the Bay development in North Naples, Florida. On October 28, 2004, he pulled onto US 41 to drive his 6-year-old grandson to a nearby Pizza Hut for dinner. An SUV slammed into their car. EMS personnel
responded quickly, but the widely acknowledged father of emergency medicine was dead at the age of 74. Judd Hollander was a young resident when he dropped by for a chat and career guidance from mentor Lewis Goldfrank, MD, the chairman of the Department of Emergency Medicine at New York University/Bellevue. Dr. Hollander already knew the pioneering physician was candid, so he wasn’t surprised at the advice about whether Dr. Hollander should pursue internal or emergency medicine: “It is probably safer doing internal medicine first,” Dr. Hollander remembered Dr. Goldfrank saying. “In case emergency medicine ‘doesn’t last,’ you’ll have something to fall back on.” In retrospect, though, Dr. Hollander is astounded at the timing. This was in the mid-1980s. Today, that period was considered to be long after emergency medicine had become entrenched as a specialty. “That was pretty amazing,” he said. “Here I was talking to one of the fathers of the field to determine what I should do with the rest of my life – even at that point, he said, ‘We don’t know where we’re going to be (in the future). You might want to try something else.’”
AN INDEPENDENT SPECIALTY
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r. Hollander and the others got the assurances they needed in a few years, when ABMS granted full, independent specialty status in 1989. That came on the 10th anniversary of the limited recognition of emergency medicine by ABMS. “Back in those days, even medicine and surgery was split within the emergency department,” Dr. Hollander said. “Now you know about everything. It was really an area that gave us an identity. The best defining moment in my time was when emergency medicine got its independent board status.” Over the past few decades, emergency medicine itself has spawned several subspecialties: pediatrics, sports medicine, toxicology, palliative and hospice medicine. ACEP recognized the American Osteopathic Board of Emergency Medicine certifications. Research has expanded as rapidly, driven by the efforts of this journal, AnVolume , . : October
nals of Emergency Medicine, and also in part by SAEM. Its roots stretch back almost far as ACEP itself, when 6 ED directors held the organizational session for the University Association for Emergency Medical Services, a strong ally in the push for emergency medicine as a specialty. ACEP managed the organization for 8 years in the late 1970s. A later merger with the Society of Teachers of Emergency Medicine formed SAEM as it exists today. In the mid-90s, Dr. Hollander recalled that the “word on the street” was that ACEP and SAEM were of separate mindsets and motives– one focused entirely on the academic, research and education, while ACEP concentrated mostly on clinicians and practices. “It takes a while when someone pre-sets you with your biases to realize that, at least in my experience, and certainly within the last 5 or 8 years, that’s the furthest thing from the truth,” he said. “ACEP has been really helpful in reaching across borders and using the tremendous infrastructure they have to help SAEM to deal with the academic mission,” said Dr. Hollander. “And ACEP has been very devoted to the academic mission, and has actually been leaders along with SAEM in helping to set the research agenda for the future, and partnerships with the National Institutes of Health, and some lobbying issues to get more research networks funded. And they have really been a tremendous resource for other emergency medicine organizations to accomplish similar goals.” The ACEP Emergency Medicine Foundation dates back to 1973 and a few thousand dollars. Several million now support that effort. Research has been aided by the ability of the advocacy arm of ACEP to secure funding for advances in technology and treatment. The organization hired its first outside lobbyist in 1975 and kept that arrangement until ACEP itself opened a Washington DC office in 1985 for what is now a staff of 12.
ACEP AS ADVOCATE
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ilkerson, the ACEP executive director, said the ability of the membership to advocate was enhanced dramatically during the longVolume , . : October
standing push to get passage of the prudent layperson standard. That 8-year effort gained passage of the standard in 47 states and on the federal level, for Medicare and Medicaid patient care. By the time the campaign ended in 2001, “it had literally developed ACEP’s advocacy infrastructure,” Wilkerson said. Chapter Political Action Committees (PACs) grew from 7 to 23. “A lot of those people literally ‘cut their teeth’ working on the prudent laypersons standard,” Wilkerson said. Coupled with that is the 911 Legislative Advocacy Network, with 1,200 ACEP members. The National Emergency Medicine Political Action Committee, set up by ACEP in 1980, has raised about $1 million annually in political contributions and causes. That ranks in the top 5 of the medical society PACs. In the scholarly and membership communications arena, the organization has gone from its first Quarterly Report in 1969 to the peer-prominent, 28,000-circulation Annals of Emergency Medicine. Priorities have also returned to what helped launch the organization in the first place – public perception and image. Wilkerson noted that as ACEP fought for recognition in the 1970s, one of its biggest allies arrived over the airwaves. Long before the popular ER television series, Dragnet’s Jack Webb was producing Emergency! from 1972 to 1978. It tracked urgent cases for Los Angeles paramedics and emergency doctors and nurses, and was credited for helping to change the American views of emergency physicians as cast-offs and incompetents. “It was actually more influential than ER for our specialty,” Wilkerson said. “It really put emergency physicians in the public’s mind for the first time, as physicians who were competent and compassionate. . .. It was the jet fuel for the specialty through the ’70s.”
REACHING OUT TO THE PUBLIC
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CEP developed a 5-year media and public relations plan in the early 1980s, and has followed up an array of publications and mailings targeting consumers and the public, to enhance ACEP as an organization looking out for their best interests.
Attention through the media also was drawn to ACEP public outreach that included the Report Card on the State of Emergency Medicine, which began in 2006, and the 2005 US Capitol Rally of more than 4,000 emergency medicine nurses and physicians, to support the Access to Emergency Medical Services Act. The goal of the ACEP initiatives extends to the future of emergency medicine for another ACEP segment–students and residents. The health care horizon shows that the next 40 years of ACEP should rival the first 40 in terms of challenges for emergency medicine. That can be seen in the emerging generation of emergency physicians. “ACEP is fighting the battles for us,” said Andrew Zinkel, MD, a resident at the University of Illinois at Chicago and 2007-2008 president of the Emergency Medicine Residents’ Association (EMRA). EMRA, which now has more than 7,500 members, was separately incorporated and is the only fully independent resident medical specialty association in the US. Its nonprofit status prohibits direct political advocacy. Members rely on ACEP, the contract EMRA manager, to lead the campaigns on behalf of students and others in EMRA training residencies and programs. Dr. Zinkel explained that many of the campaigns target issues over adequate funding for those programs and the participants. At a time when more emergency physicians are needed, Graduate Medical Education (GME) funds are not keeping pace. The $8-billion GME allocation is part of Medicare, vulnerable in an era of federal budget-cutting.
HERE TO STAY
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is program lost one residency position last year, Dr. Zinkel said. Worse yet, economic hardship deferments are scheduled to be eliminated by July 2009. “If we had to start paying our loans back, even a small portion of them, that will create problems for residents,” he said. “That’s a major issue for a lot of residents, especially like me,” Dr. Zinkel said. Salaries are similar regardless of the program location, so residents in larger Annals of Emergency Medicine 377
metropolitan areas see compensation eroded by higher costs of living. Coupled with funding concerns is maintaining the quality of the training regimens, Dr. Zinkel said. For example, in addition to the obvious problems for patients, hospital boarding is threatening the integrity of the training, Dr. Zinkel said. Residents want the exposure to the rapid-fire, real-life work of EDs confronting as many new cases as possible to give them relevant experience. Instead, he said, the practice of boarding has reduced their residency work at times to internal medicine, ie, treating admitted patients who remain in EDs for up to 48 hours. “In some cases, we’re completing their entire hospital stay,” Dr. Zinkel said. He is encouraged by several ACEP initiatives, noting that the young physician section is among the largest in ACEP. “With emergency medicine being a young specialty, we have a lot of members excited to get involved on the state and national levels,” he said. The College’s 911 Legislative Advocacy Network and other projects, such as getting new physicians involved in state boards, fuel that involvement, Dr. Zinkel said. Dr. Zinkel and veteran ACEP leaders agree that the future must focus on more emergency medicine certifications, and getting those qualified physicians distributed to areas not currently served by them. “If emergency medicine funding isn’t increased, and need for physicians continues to rise, we’re going to see the problem with having more and more non-board certified physicians and more involvement by nurse practitioners and other health care extenders, to try to pick up the areas where we’re not able to staff,” Dr. Zinkel said. “Being members of ACEP allows students and residents to get involved more in public policy areas, in issues of importance to them.” The consensus of young and established leaders of ACEP is that the socalled fad of 40 years ago is unlikely to fade away in the future. “Evolving trends in medicine, even with retail clinics, urgent care centers and other new wrinkles, may add up to problems for specialties such as nutritionists, family doctors, internists and others,” ACEP’s Wilkerson said. “But if you look
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at the popularity of our residency programs, if you look at the increased elderly population and use of EDs, and the growth of visits. . . . It is going to continue to be growing.” Sandra Schneider, MD, an ACEP board member, said the College will continue to be successful with an approach that recognizes the diversity within the specialty. She joined on her first day as an emergency physician, and noted that “there are times when I’ve not always been supporting of a particular section or particular policy. But I’ve always been grateful for the work ACEP has done.” “There are individuals who have a specific agenda in whatever area they feel like ACEP should have supported,” Dr. Schneider said. “What ACEP does is take a balanced approach, so that their response is appropriate for all emergency physicians, no matter what their practice situation is.” Dr. Kellermann said he has noticed the same collaborative spirit as ACEP has matured into its leadership role. “I’m perceiving less friction, less concern about turf and prerogative than what existed maybe 5 or even 10 years ago,” Dr. Kellermann said. “ACEP is less concerned about being at the top of the pack, and more comfortable as it plays an overarching role, particularly in the advocacy arm of emergency medicine.” There is a healthy recognition within the organization of other groups, he said: “Each contributes their own flavor and unique talent and perspective to the enterprise.” Inclusion and collegiality have been vital to the College, Wilkerson said, although he added that the broad role of ACEP requires that it continue in a leadership position. The rapid growth and expansion of emergency medicine have created some friction among the subspecialties with competing interests, making an overall organization even more important, he said. “We do try to work with these other groups, but because we feel like our mission overarches all of emergency medicine, we feel an obligation to address various aspects of emergency care, even if another group has it as their primary mission,” Wilkerson said. “. . . We don’t
just defer and outsource that to some other group.”
EMERGENCY PHYSICIANS IN LEADERSHIP ROLES
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r. Kellermann is inspired by the rise of emergency physicians within the new leadership structure of modern medicine– even federal and state agencies, hospital and health care organization management. “I think emergency physicians are particularly well suited as role leaders, because of their moral commitment to patients, as well as their talents that are required to succeed in emergency medicine–those talents lend themselves to people who can be effective in diverse settings,” Dr. Kellermann said. Emergency physicians are often finding themselves as the only doctors caring for the massive number of “have-nots” in the American medical system, he said. “Clearly, there are tremendous challenges in a system as flawed in many respects, as in our current health care system.” Dr. Zink said the key for ACEP and emergency medicine is to stay on the path that was set by the earliest pioneers in the specialty. The College has re-emphasized that in recent years. “I think that’s been a really good change in that if our patients are taken care of, and if we can advocate well for our patients, then the rest of the system will work out in terms of what we need as physicians.” “ACEP has made an effort to not just advocate for the security of the practice of emergency physicians, but is more about ensuring there is high quality emergency care for patients,” Dr. Zink said. “If we can be leaders in that regard, I think everything else will take care of itself.” Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
doi:10.1016/j.annemergmed.2008.08.007
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he founders’ blood, in fact, flows through your vessels – through every emergency physician’s vessels. Their heart has been transplanted into your heart. Don’t let them down. Keep the faith with those who kept the promise.” – Ronald L. Krome The “fad” of emergency medicine as a specialty turns 40 this year. The keystone anniversary of the 1968 birth of the American College of Emergency Physicians (ACEP) arrives in ways that founders would not have recognized in this era of modern medicine. Ronald L. Krome, MD, who retired as a Wayne State emergency medicine professor in 2004 after 43 years as a physician, was one of the early pioneers to practice emergency medicine full time. He recalled the earlier era, when a surgeon colleague asked a popular question of the time: Why was Krome interested in such a fad as emergency medicine? He reflected on the question, then thought of when they would both be at the “pearly gates” facing St. Peter. The surgeon might offer up a list that he’d “done ‘X’ number of gall bladder removals, repaired hernias and ulcers” and so on, Dr. Krome wrote. In contrast, Dr. Krome said he could tell the saint something else: “I have changed the face of medicine for all time.” Volume , . : October
ACEP’s mark comes for an organization that has grown from 8 charter members to more than 26,000 of the 40,000 US emergency physicians. From a fledgling organization fighting for the peer respect that would make it the 23rd recognized medical specialty, leaders say ACEP is now a dominant organization in American medicine. “The world is our oyster,” ACEP Executive Director Dean Wilkerson said in describing the accomplishments and the work ahead for the organization. “We have the capability, and we have the challenges, on all sides.”
ACEP TAKES THE POLITICAL STAGE
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hose sides show themselves in internal career needs as well as external issues that increasingly put ACEP in the center of some of the most controversial concerns for the future of medical care. There are academics, research, subspecialties such as pediatrics, EMS development and more. International and disaster emergency medicine are 2 of the newest focuses. Hot-button issues are in the political and public arenas, such as hospital boarding or crowding, universal health care and fundamental conflicts with insurers and employee health plans. “I think we are at the crossroads, and are the safety net, for the entire health care system,” Wilkerson said. “As an organization it becomes challenging, with a limited budget and staff and leadership,
to, you know, ‘put the peanut butter on all those pieces of bread.’” ACEP today has 29 sections and 25plus committees concentrated on specific areas of emergency medicine. Spin-off organizations are active in the academic and research fields; 53 chapters cover every state, Puerto Rico and Washington D.C. The nation’s capital includes an advocacy office as part of the 100 staff members serving ACEP. Judd Hollander, MD, the 2007-2008 president of the Society of Academic Emergency Medicine (SAEM), said ACEP has been effective in part because it has used that broad base in coordinating and supporting efforts with other organizations to benefit research and the field in general. “It has become very collaborative and really synergistic,” Dr. Hollander said. “I think the collaborative growth of the societies together has done the most to advance mission care.” The immense ACEP membership infrastructure is dwarfed only by the size of the ultimate clients–some 119 million emergency patients treated annually in the US. Brian Zink, MD, a physician, author and historian on the emergence of the specialty, said it is unique from other disciplines because the founders created it primarily in response to the needs of patients rather than physicians. “Emergency medicine arose out of almost a social phenomenon–it was patients driving them,” Dr. Zink said. “It is really the only medical field or specialty that has arisen out of a socio-political process of patients presenting for care because they didn’t have other places to go.” Medical fields overall have made significant strides in recent decades, Dr. Zink said, although emergency medicine has been the quantum leap. “The combination of the societal demand, and the patients and medicine, have really created this field, and this improved care,” Dr. Zink said. “If you look at what has changed in the last 30 Annals of Emergency Medicine 373
years in American medicine, you can make a very strong argument that the thing that is most different, and has resulted in the most progress, is the care of sick and injured people by emergency physicians.” Arthur Kellermann, MD, MPH, a past member of the ACEP Board of Directors, joined in the salutes while cautioning about the immense work ahead for the organization and emergency medicine. “We are also the front line of many of the ills and flaws of the current system,” Dr. Kellermann said. “Some 47 million Americans without health insurance; more and more doctors unwilling to take emergency or trauma calls; tremendous financial and operational constraints are being placed on the system, and there is more and more second-guessing by insurance companies and the medical-legal community and others.” Still, he said, “When you consider how far EM has come in 40 years, it has got to be one of the most astonishing stories in the last 100 years of American medical history.” “This specialty came out of nowhere, established itself, developed a political and scientific identity, and has had a profound impact on health care in this country,” Dr. Kellermann concluded. As late as a half-century ago, emergency medicine languished largely as a merely tolerated stepchild of the American health care system.
THE HISTORY OF THE “PIT”
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lenn Hamilton, MD, a past president of SAEM and emergency medicine chair at Wright State University, wrote a historical summary of the situation at many emergency departments (EDs) in the late 1960s. “Unsupervised activities that would never be allowed to occur on the wards happened daily in the ED with rarely a second thought or concern by academic chairs or hospital leadership,” he said. “The ‘pit’ was another world entirely, a distant place to be visited as little as possible.” Specialists’ only expectation was that physicians in the ED could do nothing, or “nearly anything with a little telephone guidance,” Dr. Hamilton wrote. Academics and specialists both viewed the assignment “as where you started or
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ended your practice, or a place to be exiled if you were impaired or incompetent.” Hamilton told of the summer of 1970, when he clerked for 2 emergency physicians–75 and 78 years old–in a small northern Michigan ED. For about $10 an hour, they alternated 12-hour shifts and were on call. The 2 “were wonderfully practical, welcoming, and had 100 years of medical practice between them. When in doubt, they simply did whatever book they had said, or went with their ‘gut.’ That was evidence enough,” Dr. Hamilton wrote. When the movement for change began, “It was as if a new life form was trying to arise from the most neglected part of the hospital–the unspeakable or laughable ‘pit,’” Dr. Hamilton said. “This growth was viewed by many in academic medical centers as similar to a malignancy, something requiring surgical removal or irradiation, something to be eradicated.” Internal hospital politics didn’t prevail in derailing the effort, for a couple of basic reasons. Historians cite the remarkable resiliency of the maverick emergency physicians, who knew that reform was essential. More support emerged on the public forefront. The Vietnam War had produced major advances in trauma care, and illustrated a clear need for training and expertise in emergency care. That emphasis and awareness returned home from the battlefields. An increasingly mobile populace, and modernization of medicine, were relegating house calls to the history books, and separating patients from the customary source of treatment at family physicians’ offices. Insurance and its impact had also expanded to health care, in many cases with coverage for treatment in hospitals but not physician offices. The reported number of emergency visits had already jumped fourfold from 1940 to 1955. Some hospitals in urban areas had been slowly awakening to the needs. James Mills Jr., MD, who would go on to become president of the future ACEP, upgraded ED staffing at his Alexandria hospital. It had relied on physicians splitting duties between their primary work and the ED. Mills, in part to have more time with his own family, left his family
practice and became part of a 4-physician team that served full-time in the ED. Other hospitals realized they could have models based on that “Alexandria Plan,” or the alternative Pontiac Plan. It was developed by the Michigan general hospital of that name, which assigned rotations for more than 20 doctors for monthly stints of up to 32 hours in the ED. Public sentiments were jolted by the 1966 National Research Council/National Academy of Sciences report, “Accidental Death and Disability: The Neglected Disease of Modern Society.” It decried the lack of EMS standards, saying the nation was “insensitive to the magnitude of the problem.” The numbers turned the heads of the public: In the previous year, accident injuries had killed 107,000 Americans. The report was credited with prompting the first standards for emergency care, and focusing attention on ED deficiencies and staffing as well. Among the recommendations were licensing and regular inspection of ED facilities. Ambulances– in some places, they had been little more than repainted hearses owned by funeral homes– and their personnel were facing regulations and training requirements for the first time.
“ANYWHERE, ANYTHING, ANYTIME”
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utside commentaries were still secondary to the internal influences that began building within the medical profession. Dr. Zink, in his definitive 2006 book, Anyone, Anything, Anytime – A History of Emergency Medicine, captured the unique characters that began stepping forward to carve a genuine specialty from the chaotic ED conditions. These rebels became known as much for what they weren’t as for what they were. Zink said most of them had a modest Midwest upbringing rather than Ivy League pedigree, “and they were not plugged into the medical elite in this country. They were starting something new on a grassroots basis.” Typifying this kind of revolutionary was the man most credited with creating the specialty. John Wiegenstein, MD, was born in a cabin in Missouri; he had dabbled in pursuits toward careers as an Volume , . : October
engineer in the automobile industry, then aviator, and even spent time in a seminary before settling on medicine. Research by Dr. Zink, Dr. Hamilton and others showed the struggle Dr. Wiegenstein had in just getting his medical degree in 1960. His medical school banned students from other jobs, but he moonlighted at night as an information desk clerk at University Hospital to support his wife and children. He laughed about having to “duck” when any of his professors passed the desk. Humor was darker during his ED shifts at St. Lawrence Hospital in Lansing, MI, as he recounted the series of drunks and drifters–the doctors, not patients– on hand there. He once was relieved by a dermatologist who walked in and announced he was going to get some sleep: “Call me if a life-threatening rash comes in,” that physician said.
A LIFE SAVED
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is first year at St. Lawrence, he was in the hospital when a nurse alerted him that a father was in the parking lot with a baby boy “who looks dead.” Dr. Wiegenstein quickly identified throat blockage from an epiglottitis. He knew nothing about tracheostomies for children– he would perform his first on that black-and-blue infant. Dr. Wiegenstein found that he actually enjoyed being awakened at early hours and rushing into the challenges of critical trauma care. In whatever spare time he could muster, he began sitting in on seminars and courses for surgery and other specialties, in a realization of the importance of the “golden hour” for trauma care. That drive also put him in contact with more and more physicians who shared his concerns about the haphazard approach to emergency medicine. Dr. Zink said this pioneer blended a modest personality with keen sense of mission. “Very much driven by values, he kept pursuing in a very determined way what he saw needed to be done,” Dr. Zink said, “which was to form a strong organization in order to propel good emergency care to our patients.” “John is responsible for mentoring many within the emergency medicine community, and those individuals then
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helped train me and thousands of other emergency care providers across the country,” Robert Prodinger, DO, wrote in 2004 in the Medicine at Michigan publication of the University of Michigan. “. . . Millions of patients now receive safe, quality emergency health care due to the work of John and all those who worked with him, and those who have followed. The legacy John leaves behind is enormous, and enormously inspiring.” Dr. Prodinger knew personally of Dr. Wiegenstein’s commitment. About 18 years ago, he was an orderly who searched out Dr. Wiegenstein when he was chief of emergency medicine at Ingham County Medical Center. Dr. Prodinger explained to the doctor they had met much earlier. He lowered his collar and displayed a small scar, the remnant of a tracheostomy. The doctor had performed it on him in his infancy, when his father had rushed him to the Lansing hospital. “I would not be where I am today in my career without the work of John Wiegenstein,” Dr. Prodinger wrote. “I will always be thankful for his foresight and vision, and his ability to undauntedly apply his skills to saving my life when I was a child.”
A SPECIALTY BORN
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ack in August 1968 in Lansing, Dr.Wiegenstein had delivered the birth of ACEP. He and 7 other physicians met at a Holiday Inn to found the organization with one page of bylaws, an impressive name–and little else but a determination to succeed. “We had an awful fight from the other specialties,” Dr. Wiegenstein recalled in 2003 about the 20-year effort for emergency medicine. “Surgeons thought we were invading their turf. The internists thought they might lose their resident training opportunities. People didn’t believe that one specialty could encompass all the lifesaving techniques you need as an emergency room doctor.” The longest period of calm for ACEP may have been counted in minutes, during the opening moments of the meeting to organize it. Physician Richard Lingenfelter, MD, took offense at allowing membership to anyone who voluntarily devoted a significant amount of their practice to surgery or emergency medi-
cine. He objected to including osteopaths, and parted ways with the organization. Three months later, ACEP more than tripled its membership–to 30 doctors. The group learned that another physician, Reinald Leidelmeyer, MD, had already planned to host a meeting of emergency physicians at a Marriott in Arlington, VA. At that session, Dr. Wiegenstein led the effort to get them to embrace ACEP. The organization’s first Scientific Assembly followed in Denver. Dr. Wiegenstein tapped the American Medical Association for more help in developing the educational seminars and related programs to begin establishing emergency medicine as a specialty. Expansion was rapid. The second Scientific Assembly, held in Las Vegas, drew 600 physicians and offered well-defined programs. In 1970, the University of Cincinnati launched the first emergency medicine residency program, although ACEP failed in an effort to get approval from the AMA Council on Medical Education for formal training. Dr. Zink said a landmark event was the so-called “Blue Book” meeting in 1973; ACEP had to fully document the basis for emergency medicine and residency programs and specialist training. “They had to convince all the other people from all the other specialties, and from government and the big medical organizations that there was a clear need for the specialty,” he said. “It legitimized the specialty in the kind of forum that had everyone together, which really hadn’t occurred up until that point.” The AMA granted the request for a provisional section on emergency medicine in 1973, which gave ACEP entry into the association’s House of Delegates. Two years later, that Section Council of Emergency Medicine became a permanent part of the AMA structure. ACEP led the way in creating the American Board of Emergency Medicine in 1976, which had a proposed certifying examination.
DOOR CLOSED, WINDOW OPENED
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owever, the door slammed shut on their hopes in 1977. The American Board of Medical Specialties (ABMS) jolted the movement by defeatAnnals of Emergency Medicine 375
Science and the Specialty Every specialty needs a journal in which to publish peer reviewed research, and ACEP (The Journal of the American College of Emergency Physicians, or JACEP) printed its first issue in January 1972. It contained absolutely no original science (not even a case report), and the editors stated “there will be a place for almost any conceivable contribution.” Educational content consisted of synopses of review lectures given at CME courses. The single largest content area was classified ads for jobs available (8 pages), with typical full time jobs requiring 40 or more hours of clinical, paying about $30,000 a year, and looking for applicants of any or no specialty who “can work hard and fast.” How far the journal and the specialty have come. We have changed our name (from JACEP to Annals of Emergency Medicine), and our issues are full of science rigorous enough that case reports have a very hard time getting accepted. Now Annals is the largest and most prestigious emergency medicine journal, and ranks in the top 12% of all scientific journals of any kind in impact factor and number of citations. Its stories get extensive coverage in the lay media, and its Web page received about 900,000 page views in the most recent year. Its timeliness and quality of peer review is among the best. All of this helps us fulfill our role of being the scientific voice of emergency medicine, publishing the data that will change clinical practice and will be used by our leadership to change health policy. Thanks to all the researchers, reviewers, and editors whose dedication over the years has made this come to pass. Although we are still having to work hard and fast. Michael L. Callaham, MD Editor in Chief
ing a measure to make emergency medicine a specialty. Dr. Zink, in his history of ACEP, described the inner turmoil after losing 376 Annals of Emergency Medicine
the ABMS vote. There were calls to abandon the ABMS efforts and try to establish a separate board. Dr. Wiegenstein and some College leaders instead pressed for a compromise that would give the emergency medicine conjoint board representation through other specialty boards at ABMS. “He soothed those who were reckless and implored those who were timid,” Dr. Zink said of Dr. Wiegenstein’s approach. “He was the leader emergency medicine needed at this stage of its development.” One long-time nemesis was physician Oscar Hampton, MD, who chaired the American College of Surgeons’ Committee on Trauma when ACEP was trying for Section Council status with AMA in the early 1970s. Dr. Zink’s research told of Dr. Wiegenstein’s gambit during a key hearing on the issue, when he and Dr. Hampton were to face off in front of some of the most influential forces in medicine at the time. As the issue was coming up on the agenda, Dr. Wiegenstein slipped out of the meeting so Dr. Hampton would have to go first. Then he listened just outside as the surgeon decried the idea of a new specialty identified by nothing more than the room– emergency room–where they practiced. When Dr. Hampton finished, Dr. Wiegenstein gave his spirited defense of the movement. He even raised another suggestion: Shouldn’t surgeons themselves also be known by their room, as “operating room doctors”? The ACEP leader went on a frantic lobbying pursuit of officials of other boards for their required approval of the arrangement. Plagued by viral hepatitis at one point, he recovered. So did ACEP. In 1979, ABMS recognized emergency medicine as a medical specialty.
A LEADER LOST
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r. Wiegenstein’s dedication to developing emergency medicine would lead to top positions and honors from several medical societies and associations in future years. He retired in 2001 to the good life at the Eden on the Bay development in North Naples, Florida. On October 28, 2004, he pulled onto US 41 to drive his 6-year-old grandson to a nearby Pizza Hut for dinner. An SUV slammed into their car. EMS personnel
responded quickly, but the widely acknowledged father of emergency medicine was dead at the age of 74. Judd Hollander was a young resident when he dropped by for a chat and career guidance from mentor Lewis Goldfrank, MD, the chairman of the Department of Emergency Medicine at New York University/Bellevue. Dr. Hollander already knew the pioneering physician was candid, so he wasn’t surprised at the advice about whether Dr. Hollander should pursue internal or emergency medicine: “It is probably safer doing internal medicine first,” Dr. Hollander remembered Dr. Goldfrank saying. “In case emergency medicine ‘doesn’t last,’ you’ll have something to fall back on.” In retrospect, though, Dr. Hollander is astounded at the timing. This was in the mid-1980s. Today, that period was considered to be long after emergency medicine had become entrenched as a specialty. “That was pretty amazing,” he said. “Here I was talking to one of the fathers of the field to determine what I should do with the rest of my life – even at that point, he said, ‘We don’t know where we’re going to be (in the future). You might want to try something else.’”
AN INDEPENDENT SPECIALTY
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r. Hollander and the others got the assurances they needed in a few years, when ABMS granted full, independent specialty status in 1989. That came on the 10th anniversary of the limited recognition of emergency medicine by ABMS. “Back in those days, even medicine and surgery was split within the emergency department,” Dr. Hollander said. “Now you know about everything. It was really an area that gave us an identity. The best defining moment in my time was when emergency medicine got its independent board status.” Over the past few decades, emergency medicine itself has spawned several subspecialties: pediatrics, sports medicine, toxicology, palliative and hospice medicine. ACEP recognized the American Osteopathic Board of Emergency Medicine certifications. Research has expanded as rapidly, driven by the efforts of this journal, AnVolume , . : October
nals of Emergency Medicine, and also in part by SAEM. Its roots stretch back almost far as ACEP itself, when 6 ED directors held the organizational session for the University Association for Emergency Medical Services, a strong ally in the push for emergency medicine as a specialty. ACEP managed the organization for 8 years in the late 1970s. A later merger with the Society of Teachers of Emergency Medicine formed SAEM as it exists today. In the mid-90s, Dr. Hollander recalled that the “word on the street” was that ACEP and SAEM were of separate mindsets and motives– one focused entirely on the academic, research and education, while ACEP concentrated mostly on clinicians and practices. “It takes a while when someone pre-sets you with your biases to realize that, at least in my experience, and certainly within the last 5 or 8 years, that’s the furthest thing from the truth,” he said. “ACEP has been really helpful in reaching across borders and using the tremendous infrastructure they have to help SAEM to deal with the academic mission,” said Dr. Hollander. “And ACEP has been very devoted to the academic mission, and has actually been leaders along with SAEM in helping to set the research agenda for the future, and partnerships with the National Institutes of Health, and some lobbying issues to get more research networks funded. And they have really been a tremendous resource for other emergency medicine organizations to accomplish similar goals.” The ACEP Emergency Medicine Foundation dates back to 1973 and a few thousand dollars. Several million now support that effort. Research has been aided by the ability of the advocacy arm of ACEP to secure funding for advances in technology and treatment. The organization hired its first outside lobbyist in 1975 and kept that arrangement until ACEP itself opened a Washington DC office in 1985 for what is now a staff of 12.
ACEP AS ADVOCATE
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ilkerson, the ACEP executive director, said the ability of the membership to advocate was enhanced dramatically during the longVolume , . : October
standing push to get passage of the prudent layperson standard. That 8-year effort gained passage of the standard in 47 states and on the federal level, for Medicare and Medicaid patient care. By the time the campaign ended in 2001, “it had literally developed ACEP’s advocacy infrastructure,” Wilkerson said. Chapter Political Action Committees (PACs) grew from 7 to 23. “A lot of those people literally ‘cut their teeth’ working on the prudent laypersons standard,” Wilkerson said. Coupled with that is the 911 Legislative Advocacy Network, with 1,200 ACEP members. The National Emergency Medicine Political Action Committee, set up by ACEP in 1980, has raised about $1 million annually in political contributions and causes. That ranks in the top 5 of the medical society PACs. In the scholarly and membership communications arena, the organization has gone from its first Quarterly Report in 1969 to the peer-prominent, 28,000-circulation Annals of Emergency Medicine. Priorities have also returned to what helped launch the organization in the first place – public perception and image. Wilkerson noted that as ACEP fought for recognition in the 1970s, one of its biggest allies arrived over the airwaves. Long before the popular ER television series, Dragnet’s Jack Webb was producing Emergency! from 1972 to 1978. It tracked urgent cases for Los Angeles paramedics and emergency doctors and nurses, and was credited for helping to change the American views of emergency physicians as cast-offs and incompetents. “It was actually more influential than ER for our specialty,” Wilkerson said. “It really put emergency physicians in the public’s mind for the first time, as physicians who were competent and compassionate. . .. It was the jet fuel for the specialty through the ’70s.”
REACHING OUT TO THE PUBLIC
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CEP developed a 5-year media and public relations plan in the early 1980s, and has followed up an array of publications and mailings targeting consumers and the public, to enhance ACEP as an organization looking out for their best interests.
Attention through the media also was drawn to ACEP public outreach that included the Report Card on the State of Emergency Medicine, which began in 2006, and the 2005 US Capitol Rally of more than 4,000 emergency medicine nurses and physicians, to support the Access to Emergency Medical Services Act. The goal of the ACEP initiatives extends to the future of emergency medicine for another ACEP segment–students and residents. The health care horizon shows that the next 40 years of ACEP should rival the first 40 in terms of challenges for emergency medicine. That can be seen in the emerging generation of emergency physicians. “ACEP is fighting the battles for us,” said Andrew Zinkel, MD, a resident at the University of Illinois at Chicago and 2007-2008 president of the Emergency Medicine Residents’ Association (EMRA). EMRA, which now has more than 7,500 members, was separately incorporated and is the only fully independent resident medical specialty association in the US. Its nonprofit status prohibits direct political advocacy. Members rely on ACEP, the contract EMRA manager, to lead the campaigns on behalf of students and others in EMRA training residencies and programs. Dr. Zinkel explained that many of the campaigns target issues over adequate funding for those programs and the participants. At a time when more emergency physicians are needed, Graduate Medical Education (GME) funds are not keeping pace. The $8-billion GME allocation is part of Medicare, vulnerable in an era of federal budget-cutting.
HERE TO STAY
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is program lost one residency position last year, Dr. Zinkel said. Worse yet, economic hardship deferments are scheduled to be eliminated by July 2009. “If we had to start paying our loans back, even a small portion of them, that will create problems for residents,” he said. “That’s a major issue for a lot of residents, especially like me,” Dr. Zinkel said. Salaries are similar regardless of the program location, so residents in larger Annals of Emergency Medicine 377
metropolitan areas see compensation eroded by higher costs of living. Coupled with funding concerns is maintaining the quality of the training regimens, Dr. Zinkel said. For example, in addition to the obvious problems for patients, hospital boarding is threatening the integrity of the training, Dr. Zinkel said. Residents want the exposure to the rapid-fire, real-life work of EDs confronting as many new cases as possible to give them relevant experience. Instead, he said, the practice of boarding has reduced their residency work at times to internal medicine, ie, treating admitted patients who remain in EDs for up to 48 hours. “In some cases, we’re completing their entire hospital stay,” Dr. Zinkel said. He is encouraged by several ACEP initiatives, noting that the young physician section is among the largest in ACEP. “With emergency medicine being a young specialty, we have a lot of members excited to get involved on the state and national levels,” he said. The College’s 911 Legislative Advocacy Network and other projects, such as getting new physicians involved in state boards, fuel that involvement, Dr. Zinkel said. Dr. Zinkel and veteran ACEP leaders agree that the future must focus on more emergency medicine certifications, and getting those qualified physicians distributed to areas not currently served by them. “If emergency medicine funding isn’t increased, and need for physicians continues to rise, we’re going to see the problem with having more and more non-board certified physicians and more involvement by nurse practitioners and other health care extenders, to try to pick up the areas where we’re not able to staff,” Dr. Zinkel said. “Being members of ACEP allows students and residents to get involved more in public policy areas, in issues of importance to them.” The consensus of young and established leaders of ACEP is that the socalled fad of 40 years ago is unlikely to fade away in the future. “Evolving trends in medicine, even with retail clinics, urgent care centers and other new wrinkles, may add up to problems for specialties such as nutritionists, family doctors, internists and others,” ACEP’s Wilkerson said. “But if you look
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at the popularity of our residency programs, if you look at the increased elderly population and use of EDs, and the growth of visits. . . . It is going to continue to be growing.” Sandra Schneider, MD, an ACEP board member, said the College will continue to be successful with an approach that recognizes the diversity within the specialty. She joined on her first day as an emergency physician, and noted that “there are times when I’ve not always been supporting of a particular section or particular policy. But I’ve always been grateful for the work ACEP has done.” “There are individuals who have a specific agenda in whatever area they feel like ACEP should have supported,” Dr. Schneider said. “What ACEP does is take a balanced approach, so that their response is appropriate for all emergency physicians, no matter what their practice situation is.” Dr. Kellermann said he has noticed the same collaborative spirit as ACEP has matured into its leadership role. “I’m perceiving less friction, less concern about turf and prerogative than what existed maybe 5 or even 10 years ago,” Dr. Kellermann said. “ACEP is less concerned about being at the top of the pack, and more comfortable as it plays an overarching role, particularly in the advocacy arm of emergency medicine.” There is a healthy recognition within the organization of other groups, he said: “Each contributes their own flavor and unique talent and perspective to the enterprise.” Inclusion and collegiality have been vital to the College, Wilkerson said, although he added that the broad role of ACEP requires that it continue in a leadership position. The rapid growth and expansion of emergency medicine have created some friction among the subspecialties with competing interests, making an overall organization even more important, he said. “We do try to work with these other groups, but because we feel like our mission overarches all of emergency medicine, we feel an obligation to address various aspects of emergency care, even if another group has it as their primary mission,” Wilkerson said. “. . . We don’t
just defer and outsource that to some other group.”
EMERGENCY PHYSICIANS IN LEADERSHIP ROLES
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r. Kellermann is inspired by the rise of emergency physicians within the new leadership structure of modern medicine– even federal and state agencies, hospital and health care organization management. “I think emergency physicians are particularly well suited as role leaders, because of their moral commitment to patients, as well as their talents that are required to succeed in emergency medicine–those talents lend themselves to people who can be effective in diverse settings,” Dr. Kellermann said. Emergency physicians are often finding themselves as the only doctors caring for the massive number of “have-nots” in the American medical system, he said. “Clearly, there are tremendous challenges in a system as flawed in many respects, as in our current health care system.” Dr. Zink said the key for ACEP and emergency medicine is to stay on the path that was set by the earliest pioneers in the specialty. The College has re-emphasized that in recent years. “I think that’s been a really good change in that if our patients are taken care of, and if we can advocate well for our patients, then the rest of the system will work out in terms of what we need as physicians.” “ACEP has made an effort to not just advocate for the security of the practice of emergency physicians, but is more about ensuring there is high quality emergency care for patients,” Dr. Zink said. “If we can be leaders in that regard, I think everything else will take care of itself.” Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. The author has stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
doi:10.1016/j.annemergmed.2008.08.007
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