Do we need to put emergency medicine on the endangered list?
I was walking off the stage in Athens when a small group of Philippine emergency medicine residents rushed up to me. “Please help us in the Philippines,” they pleaded. “We can’t continue working like this, 36 hours straight in the ED. Nobody wants to go into emergency medicine because the work is brutal. We love our work but just can’t go on like this!”
A week later I received an email from a Polish EM colleague describing a hunger strike by Polish junior doctors (residents) that started on October 2nd at the Medical University of Warsaw. The strike has continued for 11 days, as of this writing. A major focus of the strike is the need for increased pay and improved work standards for junior doctors who have negotiated to deaf ears with the health ministry for the past two years. We have reports of mandatory ED work schedules of 90 hours/week or more. The work schedule, of course, prevents the junior doctors from organizing, studying and teaching, and leaves no opportunity for becoming leaders who can improve the health system. A very clever method of suppression. And as junior doctor work schedules require especially overwhelming duty in EDs, the end result is a stifling of interest in our specialty. Even seasoned emergency physicians in Poland describe daunting work schedules, 24-36 hours straight. Who wants to go into a specialty like that?
The Philippines and Poland aren’t the only countries where emergency medicine is endangered.
In December, 2016, thousands of physicians who work in Kenya’s public hospitals staged a 100-day strike protesting low wages and the lack of government action to increase the supply of physicians. EDs are especially burdened by overcrowding and undertrained doctors. In April 2016, emergency physicians in the UK attempted widespread strikes in response to health ministry decisions to mandate extended evening, night, and weekend hours, and without any increase in pay .
Ask emergency physicians in Spain, Czech Republic, and Germany about the embodied institutional and specialty resistance against emergency medicine. Ask Serbian emergency physicians about their struggles to handle a hundred patients a shift with only one physician on duty.
It is confounding to think, at this 50th anniversary benchmark of emergency medicine in the US and the UK, that emergency medicine continues to be resisted around the globe. We must continue to assist our EM colleagues, but how? Are we looking for the right advocates?
The One Person Principle
EM development in the US started with one dean (University of Cincinnati) and one resident (Bruce Janiak). Early residencies developed at the hospital level. In 1971, Gail Anderson, MD, Chairman of Obstetrics and Gynecology at Los Angeles County Hospital, was appointed director of emergency medicine by a clear-thinking hospital medical director, to ‘fix up the ER’ – and quickly established the first academic department of EM in the US. These two examples show the power and influence that a single advocate of EM can achieve. Other early EM residencies in the US developed in community hospitals, and it took years to get a foothold in academia. So, finding the right advocate and developing a personal relationship is a key.
English Language Medical Schools
Here’s a stunning Polish paradox: the Medical University of Warsaw has an English-language medical school that requires tuition and has the expressed goal of training physicians to work in the West. There are several other English-language medical schools based in Poland: Medical University of Gdansk, the University of Warmia, and Mazury in Olsztyn, to mention only a few. Such English Language off-shoots should be approached and could be great advocates for emergency medicine. I have a very close friend in Poland – Polish EM boarded – and she has an impressive CV and is an excellent physician. She was turned down for a job in the UK because, “Poland does not have proper training in contemporary emergency medicine.” Well, I suppose this is a perverse way to prevent brain-drain.
The Public Health Angle
Emergency medicine is the only population-based specialty. What do I mean by that? We treat all disorders, we treat multiple patients simultaneously, and ED complaints mirror the prevalence of disorders in the population. Also, EM does primary, secondary prevention. I could go on. Focusing on the aspects of our specialty that provide important public health benefits may gain advocates in public health and health ministries.
Help Define Emergency Medicine
We continue to be challenged, even in the US, by a lack of understanding about what exactly EM is and why we need it. We need better communication methods and tools. Emergency Medicine is SYSTEM of care. Not just an episodic ED visit.
The EM system incorporates access to care, the prehospital ambulance system, the ED visit and recognition of time-sensitive illness and injury, coordination with specialists (STEMI, stroke,sepsis), and coordination with after-care (PCP, clinics). We are just beginning to see EM research that identifies emergency care as a key link in the entire chain of medical care. Adverse effects occur if our link is broken. Unfortunately, in Europe and especially in Poland, emergency care is misunderstood to be just the ambulance system – sort of free-hanging fruit that is disembodied from emergency medicine.
Health Care Economics
Every country needs to save money on health care costs. Emergency Medicine saves hospitals money in many ways, but there is little financial documentation available to convince hospital directors. Examples of cost-saving maneuvers include: ED observation units that save hospital admissions, elimination of unnecessary ED specialists or consultations, providing hospital admissions only when necessary, providing the right care at the beginning, and streamlining care of time-sensitive conditions. Despite the body of literature on the care for conditions like STEMI, stroke, and sepsis, I have yet to find material that provides data on how EMS and ED care have improved door-to-balloon or door-to-tpa times.
Use the Media
Newspapers, newsletters, blogs, posts, and social media can be very effective tools for communicating the value of emergency medicine. Even in the US, descriptions of care for mass shootings or disasters typically focus on first responders and surgeons. Reporters seem to think that trauma surgeons are sitting in the ED, just waiting for the next trauma victim, and unaware that patients cannot get to the OR without the ED. EM social media tends to communicate within-specialty but not outside-specialty. Every newspaper article that omits the role of emergency medicine in such situations should get a letter from our national or state organizations reminding them that there is an ED and EM physician 24/7 that is treating the patient and organizing care.
Mark Reiter asks the question, “Do emergency physicians need a labor union?”
Gary Gaddis weighs in on emergency medicine’s prospects in Europe.
I would agree with your perception that EM is a different animal in the US than in many other countries. In particular the German care environment which I know well, suffers from the lack of recognition of the value of emergency medicine as a specialty. The past years have also not been very encouraging in spite of Dr. Barbara Holden in Hamburg having been the president of EuSEM and Dr. Christoph Dodt tirelessly fighting for the specialty as head of DGINA (German Emergency Medicine Association). Deeply engrained structures of the health care system seem to prevent change. These are both in the financial arena (inpatient and outpatient medicine are paid by separate payment systems) as well as the system of the traditional specialties who are not likely to give up turf.
I would believe that we, as the matured specialty we have become in the US, could possibly do more if we found a way to assist in the understanding of the processes in EM. We are not just another specialty, we are critically different in the way we approach medicine. While most other specialties are becoming more and more specialized, we are the masters of acute and critical care, always ready for the unknown and unplanned, and constantly realigning our priorities and focus. We slice the medical specialty cake horizontally, not vertically the way our colleagues do. And by doing that, we do not only benefit our patients, but also our specialty colleagues (who we critically depend on) by matching patient’s pathology with their expertise. This process at the entry point into the health care system should be recognized as the benefit it is.
While the critical life saving procedures we do fuels our everyday life as emergency physicians and also often finds media coverage, the much less spectacular sorting and prioritizing of large numbers of patients and putting them on the right track into the health care system is probably the most valuable process we are contributing. Quantifying this contribution in health care dollars saved by its efficiency would likely find the attention of important decision makers and help getting us off the endangered list.
Very well your comments on the problem that is happening in Poland with emergency residents, in Mexico where I live and learned of emergency medicine, the specialty is becoming increasingly important, modifying the old ways where the emergency departments were where they put the doctors “punished”, “rebels” or with less knowledge, this little by little is changing, however with 30 years of history of the specialty of emergency medicine, there is still a long way to go. Even the salaries of doctors in public hospitals is low, which makes colleagues look for two or more working days in different hospitals, and the private work in emergency medicine is not yet well valued and is poorly paid, there are very few Emergency medical specialists in the emergency rooms of private hospitals, as well as in public hospitals, few emergency specialists in Mexico graduate each year, much remains to be done.
But in Mexico there is a lot of work to organize the health systems, since the emergency services are always “saturated” and not only due to the lack of specialists in the emergency room, but also due to the lack of doctors from the rest of the specialties and resources to diagnose and give definitive treatment to patients, almost always turning emergency services into another “area of hospitalization” where patients can even enter, diagnose, treat, and go to their home, from the same emergency room , with times of stay in the emergency room including 36 to 48 hours or more.
We have to promote a transversal and integral policy, where it is established that emergency medicine is formed not only by the survival chain, but by the strengthening of health systems, because health systems that do not work in routine , they will not work in disaster or emergency situations, where emergency medical attention systems are vital, just like medical specialists in emergencies.