Emergency physicians are medical doctors who have extensive education and training in emergency medicine. They provide rapid assessment and treatment of any patient with a medical emergency, and they are responsible for the initial assessment and care of any medical condition that a patient believes requires urgent attention, and those who lack access to other avenues of care (Schneider et al, 1998). Doctors in this medical field provide both direct patient care and coordination of comprehensive medical care for that patient.
Emergency physicians are first-contact providers to patients of all ages and populations regardless of the injury or illness they are suffering from. They provide rapid treatment and stabilization of true emergencies, as well as rapid differentiation between emergent and non-emergency conditions over the spectrum of disease process (Schneider et al, 1998). Most emergency physicians work in hospitals, although some may provide treatments during emergency transport situations, or part as an emergency response team. Others may work in urgent care clinics or observation medical units.
Emergency physicians in the U.S. emergency departments and sometimes other settings provide urgent and emergency care to patients of all ages, including definitive diagnosis of emergent conditions, prolonged stabilization of patients when necessary, airway management, and life-saving procedures using rapid sequence intubation and sedation (Suter, 2012). They use a multitude of diagnostic technologies including laboratory studies, ultrasound and other sophisticated radiology, such as CT scans, and MRIs.
The type of care performed by an emergency physician is typically divided into three tiers: urgent, non-urgent and emergent. According to Schneider et al (1998), nearly 40% of the patients seen by an emergency physician are urgent (severe but not life-threatening), 40% are non-urgent (issues that would be treated by a primary care physician), and 20% are emergent (life-threatening). An emergency physician must be able to differentiate between the cases presented to treat the most severe cases first.
Physicians specializing in emergency medicine are unique medical specialists who provide highly technical and sophisticated care to the most emergent patients (Schneider et al, 1998). At times, they also act as primary care physicians to assess symptoms and coordinate a comprehensive medical care plan, which may include referrals to other specialists, but they do not provide long-term care. The main focus of this medical discipline is the initial management of critically ill patients.
Emergency Medicine
Emergency Medicine is a medical specialty field that is dedicated to the diagnosis and treatment of unforeseen illness or injury. It involves initial evaluation, diagnosis, treatment, coordination of care among multiple providers, and disposition of any patient requiring expeditious medical, surgical or psychiatric care (ACEP, 2015). Physicians specializing in emergency medicine also have training in the planning, oversight and medical direction for community emergency medical response, medical control and disaster preparedness, in addition to providing valuable clinical, administrative and leadership services to the emergency department and other sectors of the health care delivery system (ACEP, 2015).
Emergency medicine is considered the health care safety net in the United States. Emergency medical care is considered a standard and required part of a community, just as a police or fire department is considered essential. For some people, particularly those in rural areas, primary care can be difficult to access, and emergency care is the only option for receiving any health care, even if it is a non-urgent need.
The History of Emergency Medicine in the United States
Although the beginnings of medicine date back to ancient times, emergency medicine in the U.S. emerged around the 1960s. Prior to the 1960s, emergency rooms were typically staffed with a variety of employees, including interns, residents, and rotating shifts between specialists such as psychiatrists or pathologists. There was no coordination or organized care, and most of the ambulance services were run by morticians or funeral directors.
In 1961, physicians began to leave their private medical practices to staff emergency room departments in Alexandria, Virginia and in Pontiac, Michigan, because there was a realization that there was a need for specialists in emergency medicine who would be available to patients at all times day or night (Suter, 2012). This was the beginning to the development and acknowledgement for coordinated, organized and specialized emergency care. Without the establishment of emergency medicine, there would be no 24-hour care with specialists available, and there was confusion as to which specialist should treat which patients.
As the U.S. pioneers moved forward, they received support in the form of the 1966 National Academy of Sciences “White Paper”: “Accidental Death and Disability, the Neglected Disease of Modern Society” that described the poor state of emergency care in the U.S (Suter, 2012). This led to the passing of the 1965 Federal Highway Safety Act, which set standards for ambulance and emergency care training in the United Stated. Compared to emergency treatment of soldiers in the Vietnam War, the civilian emergency care system was significantly lacking in services.
Other developments influenced the establishment of emergency medicine in the U.S. were the introduction of CPR as a resuscitation measure, the federal government began paying for in-hospital services through Medicare and Medicaid, leading for increased public demand and better quality of all types of healthcare services (Suter, 2012).
Establishing Emergency Medicine as a Medical Specialty
In 1968, the American College of Emergency Physicians (ACEP) was founded by a group of physicians in Michigan, led by John G. Weigenstein. Branches almost concurrently opened in Virginia, and the groups merged into one as the ACEP. The goals of the ACEP were to develop emergency medicine specific educational conferences, textbooks and training materials, and to attain specialty board status and recognition, so that emergency medicine could only be practiced by qualified and certified emergency physicians (Suter, 2012).
Four years later, in 1972, the American Medical Association (AMA) officially recognized emergency medicine as medical specialty field and established a section dedicated to emergency medicine. To get approved from the American Board of Medical Specialties (ABMS), the ACEP developed standards for education and training, which led to the development of the Residency Review Committee (RRC).
The next year, 1973, saw the passage of the federal Emergency Medical Services Systems Act (Public Law 93-154) that funded regional and local EMS services, and in the private sector, the Advanced Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS) courses were developed in the 1970s (Suter, 2012). A combination of the popularity of “Emergency”, a television show depicting paramedics and emergency room doctors (which increased public expectations) and the large number of pilots returning from Vietnam, there was a significant expansion in aero-medical transport services, which are considered common today.
The International Federation for Emergency Medicine (IFEM) arose out of the advances in and acceptance of emergency medicine as a medical specialty field not only in the United States, but in other countries as well. The IFEM established the following definition of emergency medicine (Suter, 2012):
“Emergency medicine is a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of episodic undifferentiated physical and behavioral disorders; it further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development.”
Academic Advancements
In the early 1970s, residency programs in emergency medicine were established at the University of Cincinnati and the University of South Carolina, as well as at the Medical College of Pennsylvania. The initial emergency medicine residency programs were two years in duration, and required the completion of an internship. In 1980 these were standardized to a minimum of 24 months of emergency medicine, and 36 months of total training and in the late 1980s became a minimum of 36 months of emergency medicine training, with some programs lasting four years (Suter, 2012).
Following the establishment of residency training programs, the University Association for Emergency Medical Services (EMS) and the Society of Teachers of Emergency Medicine were formed to provide means for academic emergency physicians to interact (Suter, 2012). These two organizations merged in 1990 to what is still known as the Society for Academic Emergency Medicine.
The success in both clinical and academic arenas gave ACEP the confidence to fund the establishment of the American Board of Emergency Medicine (ABEM) in 1976, and within three years, the independent ABEM received specialty board approval in 1979 as the 23rd medical specialty in the U.S. (Suter, 2012). The formation of the ABEM led to more advances in the education and training requirements for emergency medicine physicians. The main focus was on residency training, and the completion of a certain number of residency training hours was needed in order to obtain board certification.
In 1989, the ABEM was awarded primary medical status, so it was no longer a specialty, but its own independent medical field. This also allowed for the development of sub-specialty certifications.
Emergency Medicine 1990 – Present
In the 1990s, U.S. emergency medicine continued to grow, and this growth was fueled by the entertainment industry, which glamorized the specialty in movies and shows such as “ER” (the role of the media cannot be underestimated) (Suter, 2012). The expansion in public knowledge and awareness (and expectations) of emergency medicine was a factor in the promotion of the value in and the growth of this field. This also included the development and growth of pre-hospital emergency medical care, provided by paramedics, firefighters or police officers, in most cases.
Other factors that advance the need for emergency medicine are improved overall medical system development, rapid urbanization causing transition from infections to trauma and cardio-respiratory disease, increasing demand for outpatient medical visits, the success of emergency medicine in other high-profile countries increasing expectations, international travel, and terrorist or other mass casualty events (Rochefort, 1996).
Emergency Medicine Today
The United States CDC data show increasing demand for emergency services in the U.S., as recent data for 2009 showed 124 million emergency department visits compared to 90.3 million in 1996 (up 35%) - this was an average of 41.5 visits per 100 persons compared with 34.2 in 1996 (up 18%) (Suter, 2012). More than half of the emergency services provided are to people over the age of 75, but all emergency room patients have varying between the urgent, non-urgent, and emergent stages.
Emergency medicine is one of the popular choices of students entering residency programs, as is the case in other countries with established emergency medicine programs. While there was some initial resistance, there was a realization that emergency medicine is a consulting specialty that does not take patients from other physicians, enabling other specialties to practice more efficiently by eliminating disruptions to their office and hospital rounds schedules (Suter, 2012). Currently, there are more than 35,000 emergency medicine physicians (over 25,000 are board certified) and nearly 200 residency programs established in the United States.
Sub-specialties in emergency medicine include toxicology, pediatrics, emergencies and disasters, critical care, hyperbaric medicine, administration/policy management and research (Suter, 2012). In 2007, the World Health Organization (WHO) passed a resolution to encourage all countries to establish trauma and emergency care services to anyone who needs them.
Current Challenges in Emergency Medicine
The four biggest challenges for U.S. emergency medicine are professional liability, reimbursement, surge capacity, and workforce projections (Suter, 2012). Malpractice lawsuits, healthcare payments, over-crowding, and the future of residency training programs present great challenges to emergency medicine physicians. Because of the challenges to emergency medicine, many emergency physicians are overworked and face overwhelming numbers of patients during one shift.
The frequency of malpractice charges is a great concern to most emergency physicians, as well as other physicians. It has become so common that it is sometimes referred to as a “lawsuit lottery”, taking the stigma away but affecting access to care, and adding billions in costs from high liability insurance premiums and more importantly other costs of “defensive medicine” including unnecessary testing and treatments (Suter, 2012).
Emergency medicine providers do not screen their patients for healthcare, and they are required to see any patient regardless of their insurance or lack thereof. Throughout the last two decades, this has been a frustrating issue for many emergency medicine physicians who face increased public demand and dwindling reimbursement amounts. Increasing public demands fewer resources and a lack of good societal decisions regarding what to pay for are requiring us to see progressively increasing numbers of patients with decreasing resources (Suter, 2012).
Crowding of emergency departments has led to reduced surge capacity in the emergency care system (Suter, 2012). Due to a variety of issues, most emergency rooms are continuously over-crowded and often reach levels near their maximum capacity. A lack of nurses and lack of in-patient hospital beds often leads to an overwhelming situation for some emergency medicine physicians. There are many more elderly and complex patients due to shifting demographics, and they often require admission to a decreasing number of inpatient hospital beds (Suter, 2012).
There is an expected decrease in emergency medicine residency students in the next two decades, which will lead to additional shortages and challenges for practicing and future emergency physicians. Many other countries are also facing similar shortages, although most do not face the same health care and reimbursement issues.
Being an emergency physician can be extremely stressful, with very long and irregular work hours spent on their feet in a fast-paced environment. There are benefits to becoming an emergency physician as well, including the satisfaction of helping people with severe injuries or illnesses and a decent salary.
How to Become an Emergency Physician
To become an emergency physician, a doctorate degree and a medical license are required, in addition to the completion of an internship or residency training program. An undergraduate degree, medical school, and a residency are all required to become an emergency physician, and some may choose to complete a fellowship program as well, although it is not required.
Undergraduate Degree
The first step toward becoming an emergency physician is to complete an undergraduate degree. A high GPA and participation in multiple extra-curricular activities and volunteering at a medical center or hospital is highly recommended in order to be accepted into an accredited medical school. These programs are extremely competitive, so it is important to make the application stand out. A student may choose any major, as there is not particular major required for medical school acceptance, although many choose to major in pre-medicine, biology, or chemistry, while others may choose a social science such as humanities, sociology or psychology.
The Medical College Admissions Test (MCAT)
Medical school requirements may include coursework in biology, physiology, organic chemistry, English, math and physics, so a major that will incorporate these classes should be considered. Typically, the Medical College Admission Test (MCAT) is taken in the third year of the undergraduate program. Students must pass the MCAT to be accepted into an accredited medical school program. The higher your MCAT score, the more choices you will have to be accepted into the most elite programs.
The MCAT will assess the student’s readiness for medical school and analyze their critical thinking, problem-solving and writing skills, in addition to testing their knowledge in physical sciences, biology sciences, verbal reasoning and writing.
Medical School
After completing medical school, a Doctor of Medicine (M.D.) degree or a Doctor of Osteopathy (D.O.) degree will be awarded. Typically, a D.O. degree requires an additional year of education and training, but programs may vary depending on the school. During medical school, students spend the first two years in classroom and laboratory settings studying microbiology, anatomy, pharmacology, medical ethics, physiology and immunology.
The second two years of medical school involve clinical rotations in a hospital under the direct supervision of a licensed, experienced physician. The medical students rotate between different areas, such as emergency medicine, cardiology, gynecology, psychology, orthopedics and others. They will perform basic duties such as documenting medical histories and measuring pulse or blood pressure. Some students choose to complete an internship prior to completing their last year of medical school, although it is not required.
Residency and Fellowship Training
Because licensing requirements vary by state, it is recommended the physician complete the residency and fellowship training in the state they wish to become licensed in. A residency in emergency medicine typically lasts 3 to 4 years, and it involves attending conferences and lectures and laboratory and clinical training. Resident students will begin to observe emergency medicine physicians and may participate in some basic direct patient-care procedures.
A one-year fellowship program is not required to obtain a license, but it does allow for additional patient care training and education, as well as the opportunity to explore an emergency medicine sub-specialty.
Licensing and Certification
The United States Medical Licensing Examination (USMLE) must be taken and passed to become a licensed emergency medicine physician. Typically, the USMLE is taken right after graduation from medical school. Licensing requirements vary by state, so there may be additional requirements or examinations depending on the state the physician works in.
Certification can be obtained from the American Board of Emergency Medicine (ABEM), the American Board of Physician Specialties (ABPS) or the American Osteopathic Board of Emergency Medicine (AOBEM). Both organizations require the physician to pass a written and clinical examination to become board certified. Certification requires the physician to receive continuing education through seminars, conferences or other training opportunities.
Job Prospects
The Bureau of Labor Statistics (BLS, 2017) projects a 15% growth by the year 2026 for all physicians and surgeons, which is much faster than average compared to other occupations. The median annual income for physicians is close to $208,000, or more than $100 per hour. The number of jobs in this occupation was 713,800, with more than 106,500 openings projected in the near future. While the job of an emergency medicine physician is demanding and extremely challenging, it does have its benefits, and one of them is a significant salary.
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