I recently had the privilege of watching my son-in-law open his envelope to learn where he had matched to receive his post graduate training in emergency medicine. Having worked so hard for so many years to get to this point, I’m sure he felt both a sense of exhaustion and relief.
Every program nationwide had at least 12-15 solid applicants for each of their 10-20 openings. When these successful applicants finish their training they will go on to hopefully have promising careers. They don’t know that this was a long day in coming — much longer than any of them can imagine.
Do any young readers know why the area we have worked in all these years is called an emergency room? It’s because it used to just be one room. Many years ago, I worked at a hospital that still had that one emergency room. It was located at the back of the hospital and was locked. Patients presenting to the ER had to ring a bell for a nurse to answer and bring them in.
In some cases, trauma patients were brought in ambulances run by funeral homes. My 91-year-old father -in-law still tells stories of wild ambulance runs to car accidents in the middle of the New Mexico desert. A ride in a hearse on the way to the hospital was just the beginning of the tale for patients.
Typically, the “doctor” called to see the patient was the lowest, youngest, dumbest intern in the hospital. He, or sometimes she, actually lived at the hospital, which is why they were called “residents.” Many doctors eventually married nurses because they were the only women they met. If they were paid at all, it was a pittance. They virtually had no outside expenses.
I got to experience a little piece of this history when I reported for my training in 1979. The hospital issued me several sets of clothes — not just coats, but clothes including pants, shirts and everything … except underwear.
We were given meal tickets to the hospital cafeteria and since most of us didn’t have families, we could come eat in the hospital free on weekends.
Our education was submersion learning, which didn’t occur at the tutelage of an experienced emergency physician. It was see-one, read-one, do-one. An experienced nurse might be the only help a young frightened intern would have, a scenario I faced during my last months of medical school.
Rumors were passed around at our med school that a nearby rural hospital would hire fourth year medical students as “nurse technicians” to run their ER on nights and weekends. They were too small to even have interns so I did it. I was never more terrified.
I directed codes while glancing down at the EKGs for Dummies book. I did a Kocher maneuver to reduce a dislocated shoulder having never seen one before. It wasn’t just that I’d never seen the maneuver performed — I had never seen a dislocated shoulder. The book didn’t say anything about giving the patient sedation. I was sweating and straining so hard I couldn’t hear the patient screaming.
Another instance, I directed the staff to perform CPR on a patient for over 30 minutes, only to find out that the patient was found dead at home and only brought to the ER for pronouncement and certification. That was an awkward conversation with the family.
This is all to say that the world was ready for the beginning of emergency training in the 1960s. Patients were starting to come to ERs in droves when they found that Blue Cross/Blue Shield would pay for an ER visit when they wouldn’t pay for an office visit to their doctor.
The timing was ideal as society was getting more violent and cars were getting faster and more dangerous. Some doctors got together and created the American College of Emergency Physicians. There was actually a debate in some of the first issues of the College journal on how they should be identified. A half dozen or so hospitals decided to train emergency physicians.
All in all, it was a great time for a young medical student like me to wade into the best medical career in the world. There was one problem. Big academic institutions, like mine, weren’t ready to encourage EM careers.
When he heard I was applying to an EM program, my academic advisor actually sent a note around to my other professors suggesting that they counsel “this young promising medical student not to waste his time on a career working in the ER.” My medical school was so opposed to the notion of EM that my residency choice was not announced at the match or at graduation.
They announced I was going to Akron, Ohio…to do what? Work in a 7-Eleven? They wouldn’t say. I got my revenge many years later when I found out that my advisor, a general surgeon, had eventually gone into full time emergency medicine and had even become the president of the State ACEP Chapter.
When I arrived at Akron General Medical Center to begin training in emergency medicine with the other two people in my class of residents, we quickly learned that we would be the eternal interns. Regardless of what year of training we were in, when we rotated through other services (and that is what we did most of the time) we would take the intern’s call rotation. It was humiliating, but it was a great education.
Since I had came from Missouri, where you can sit for the Federal Licensing Exam the day after graduation, I was one of the few interns who arrived with a full license to practice medicine. That meant I could moonlight in any rural hospital ER crazy enough to hire an intern, and there were many.
In those first years out of residency emergency medicine was in chaos. Hospitals were hiring residents with one year of attending experience to be department heads. Emergency medicine groups were taking over hospital EDs where not a single doctor in the group had more than a year or two of experience.
Groups formed, dissolved, reformed, and expanded. Advances in diagnostic capability, point- of-care testing, trauma resuscitation, and much more occurred at an amazing pace. It wasn’t long before the nation went from one that didn’t know what an emergency physician was to one that demanded a board certified emergency physician for every patient.
Along with the recognition of a rapidly evolving expertise there was the reward of compensation. Since those first years out of training I’ve seen compensation double, triple and then quadruple. Today, emergency medicine is a highly respected specialty with incredibly competitive residency positions.
There has been a lot of water under the bridge since emergency medicine began so many decades ago, and the country is better for it. The expertise in today’s emergency departments is staggering. People are alive and well today for the care they receive in the nation’s EDs.
A myriad of opportunities for impact on our country’s health care system sits squarely in the hands of today’s emergency medicine residents. To a large degree they will shape the transformation of the American health care system in the future.
My hat’s off to all the medical students who have received one of those coveted training slots to begin their training in earnest for a career in today’s emergency medicine. They are smarter, more compassionate, more savvy, and more forward thinking than I was at their age.
But there is one thing they may not know. When they sit where I do now, the field will have changed just as much as it did in my career. It’s hard to even imagine.