The success of the past, the promise of the future

The success of the past, the promise of the future

Editorials The Success of the Past, the Promise of the Future As The American Journal of Emergency Medicine celebrates its 10th anniversary with some...

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The Success of the Past, the Promise of the Future As The American Journal of Emergency Medicine celebrates its 10th anniversary with some cosmetic changes and an expanded Editorial Board to meet the success attendant to a decade of growth, it seems timely to indulge in reflection over the past 10 years and to anticipate the next 10 years. Many of the subjects will have been discussed on these editorial pages since 1981, but we can also expect new themes to dominate emergency medicine in the 1990s. Emergency medicine, particularly academic emergency medicine, has indeed come a long way. Yet the pace of change in medicine today leaves us little time to bask in our accomplishments. Much of our perceived and real progress can be judged only relative to the problems facing the traditional specialties. Many of our current cavils have at least as much to do with medicine and its delivery (or lack thereof) in general as to anything intrinsic to our specialty. In certain respects, we have fared and acquitted ourselves quite well over our first decade of formal existence. We seem to have weathered the malpractice storm intact and inured, and now other specialties are the current target of opportunity for avaricious attorneys. (How long has it been since you’ve heard of a residency-trained and boardcertified emergency physician losing a malpractice case in court?) Also, it appears that the trend to outpatient care and reimbursement changes will effect our practice far less than other specialists. Research remains an unfinished agenda, and fulfillment does not seem evident in the immediate future. No specialty can hope to be very competitive or successful in this arena without a dedicated constituency in the National Institutes of Health/federal research organization. We are not alone in this regard, but in this climate of fiscal austerity, we must begin to explore clinical subspecialization in compensable fields and research in fundable cross-disciplinary areas (eg, outcomes, health care delivery, decision analysis, costbenefit analysis, etc) that relate to the practice of emergency medicine in the broadest sense. Who could have foreseen the level of our involvement in ambulatory care, urgicenters, occupational health programs, or hyperbaric oxygen therapy? This is a difficult time for any specialty to be experiencing scientific adolescence, but it is evident we cannot sustain a viable, funded future for research for our specialty if we limit our efforts to clinical toxicology, emergency medical services, education, cardiac resuscitation, and even trauma. We must develop new avenues of scientific growth in the coming decade. As the specialty comes of age, we will have to focus increasingly on manpower and training issues. There has been an explosion of student interest in emergency medicine, but this interest has not been as broad or as deep as one would like. Emergency medicine still continues to attract a disproportionate number of nonminority males with substantial educational debts from private medical schools. Furthermore, this indebtedness is not balanced by medical school performance or exposure to research that would auger for an ap-

preciable yield of faculty from this group. We run the risk of being identified as the residency training experience offering maximum income with minimum training. We need to cultivate the interest of patient, scientifically inquisitive medical students who will have the inclination and exposure to become the faculty that will train future generations of emergency physicians. Closely related is the recently identified attrition of mature emergency physicians. While this rate seems to be less than feared, it also appears to be appreciably greater than most other full-time specialists in other fields and it occurs at a considerably earlier age. Despite rapid expansion in the number of residency programs, we are only making slow progress toward staffing most emergency departments with trained and certified emergency medicine specialists. Most pressing is the dearth of faculty and the immutable demands of a 24-hour practice that make retention even more problematic than for the specialty as a whole. Faculty increasingly express concern that they will have to choose between being an emergency physician and being on the full-time faculty by the time they reach the age of 45. (Indeed, how many of you reading this page are over the age of 45?) Retention, career development, and changing practice patterns will represent major challenges to the specialty. A major struggle likely to emerge will focus on privileges and procedures in the emergency department. Traditional specialties are rediscovering our clinical venue as a component of their practices. Competition for treating and billing for patients sent to the emergency department is heating up during the day and early evening shifts. Furthermore, these same specialists are scrutinizing our privileges and advocating restrictions on our practice (eg, reading electrocardiograms and x-ray films, performing diagnostic ultrasounds, etc). On balance, though, I suspect our resilience, vigor, and flexibility will be enormous assets during the 1990s. Traditional specialties will inevitably lose influence as the largesse and organ system orientation of medicine responds to the public’s demands to produce cost-effective health care rather than procedures performed by narrowly trained (and rarely available) specialists. The future holds great promise for emergency physicians to emerge as leaders in organized medicine as we consolidate gains and grow in different directions. The American Journal of Emergency Medicine will reflect these developing arenas in its future pages, contributions, and commentary. With the profound and uncertain changes in store before the next century, our specialty will be well served by the presence of a major resource conspicuously absent in 1980: a stable, successful, and respected independent, peer-reviewed journal. The American Journal of Emergency Medicine may look different, but its mission and standards will remain steadfast. J. DOUGLAS Editor


MD, MPH 95