The city of Cincinnati, nestled along the Ohio River, which separates it from Kentucky, has a rich history. Once referred to as Porkopolis for all the pigs it processed, and known in the 1800’s for its bustling steamboat trade and German breweries, Cincinnati is also the birthplace of emergency medicine (EM) residency training and has hatched many leaders in the field. Why did EM education arise in this this Midwestern city? The answers to this question are complex, but understandable if the history of the city and medical community of the late 1960’s is considered.
The latter years of the 1960’s were a time of turmoil and “civil unrest” in many US cities. Riots, often emerging out of racial strife in African American communities, occurred in Detroit, Los Angeles, Kansas City, and other US cities. In most cases riots stemmed from poor living conditions, and problems with police and public safety. Riots occurred in Cincinnati in 1967 and 1968, with many of these factors contributing. However, according to medical leaders who worked in Cincinnati at that time, concerns about poor medical care, a dysfunctional emergency department, and access to care were also expressed by rioters. Some marched to the grounds of Cincinnati General Hospital to protest.
Hoping to quell further unrest, Cincinnati city officials and hospital leadership responded to this call-out by the community by trying to improve emergency and primary care. The emergency department (ED) at Cincinnati General was seeing over 100,000 adult patients at the time, and was staffed only by interns and residents with attending physicians serving as remote consultants. Long wait times, medical errors, and poor service were the rule, not the exception. Hospital administration tapped an inexperienced but well-regarded new internist/hematologist, Dr. Herbert Flessa to make changes. They gave him the small task of overseeing the busy ED and outpatient clinics. Flessa had no real EM experience. He received complaints from internal medicine and surgery residents who were very unhappy about being assigned so much time in the ED. Flessa became aware of the early organization of EM into the American College of Emergency Physicians and made some contact with early ACEP leaders. He had the idea that a training program in EM might attract physicians who actually wanted to work in the ED, and in 1968-69 he began exploring how to make that happen. The American Medical Association (AMA) was the certifying body for residencies at that time, so Flessa submitted an application to the AMA for a 2 year EM training program (post internship). The program was initially approved under the newly formed specialty area of Family Practice.
Flessa now needed a guinea pig to try out his program. University of Cincinnati medical student Bruce Janiak turned out to be the perfect person to take the leap as the first EM resident. Janiak had become interested in this new type of practice and heard about Flessa’s plan. After his intern year (1969-70) Janiak walked in to the ED at Cincinnati General with a loosely concocted curriculum that would allow him to spend as much time as he could in the ED, but to rotate on other services, where there were actually trained specialty attending physicians who could teach him. Flessa, despite getting the program started, was minimally involved in educating Janiak. In the ED, Janiak had an office, and a great deal of flexibility in his “training”. He worked up patients for residents on medicine and surgery services and shared a beer with them in his office at the end of long days. He noted that his one interaction with an attending physician in 2 years in the ED was when the Cincinnati student health physician who was passing through, briefly examined a patient and said “Aha, the classic doughy abdomen of abdominal tuberculosis”, and walked away.
The 2nd EM residency class at Cincinnati had 5 residents, who taught each other and developed a “band of brothers” mentality as it related to the rest of the medical center. The program came perilously close to folding in 1977 when the internist who was functioning as the program director left. A plan to put EM under the Department of Surgery was advanced by the Dean, but resisted by the EM residents. Richard Levy, who had just completed his Chief Resident year and was taking an extended vacation with his wife, was reached in Fiji and implored to come back to Cincinnati to rescue and lead the program. Levy, wise beyond his 30 years, assumed control for the residency and the entire ED. He successfully negotiated a funding scheme and resources for EM with the hospital leaders and Dean that would allow him to develop a true EM faculty and academic program. Over the next decade, Levy retained Cincinnati EM residency graduates and recruited key EM faculty from around the country. The residency program blossomed, research initiatives started, and the quality of care for patients dramatically improved. Cincinnati became an important breeding ground for academic EM as faculty and residency graduates moved on to leadership positions at other institutions around the US.
The consequences of civil unrest and turmoil can be grim and destructive, but in the case of Cincinnati, one of the responses to people marching in the streets was an innovative plan to train physicians to work in ED’s. The positive result of that first foray in to residency training in EM – according to the ACGME we now have 191 EM residencies and 6,639 residents in 2016 – has changed the landscape of American medicine and improved emergency care for millions of people. Now, in addition to pork, and beer, and the Reds and Bengals, Cincinnati can be celebrated as the birthplace of emergency medicine training, and launching pad for hundreds of emergency physicians over the past five decades.
This article was derived from Dr. Zink’s book, “Anyone, Anything, Anytime – A History of Emergency Medicine” (Elsevier-Mosby, 2006). Quotes from Drs. Flessa and Dr. Janiak are from interviews conducted by Dr. Zink in 2002.