My perspective on the history of emergency medicine.

One hundred years ago, virtually all medicine was emergent and nearly all physicians were generalists. Patients sought out physicians for pain relief or for treatment of injuries. Therapy was much more likely to be given in a patient's home or a physician's office than in a hospital setting.

Then during World War II and later in the Korean War, physicians in the military began to evaluate soldiers in a pattern known as triage. The sickest were seen and treated first and as antibiotics and tetanus vaccines became more readily available, patients with devastating injuries survived their first injuries and transferred into long-term care programs through the Veterans Administration Hospitals.

During this time in civilian practices, specialty medicine began to develop and specialized care for patients began to intensify. However, even as the first CCU's and ICU's appeared in the 1960s, many hospitals did not yet have emergency departments and relied instead on an admitting doctor or "officer of the day" to monitor patients who might need admission. Other specialists covered this service for hospitals, and many of the physicians who first practiced emergency care were in fact either interns, residents or nearly-retired physicians who wished to slow down a bit and enjoy the more regular hours emergency medicine could offer.

It wasn't until the 1970s that physicians began to be specifically trained for the emergently ill or injured patients. The American Board of Medical Specialties recognized emergency medicine in 1974, and the first board examination was written in 1978.

In the 1980s, physicians who exclusively practiced emergency medicine began to take care of patients in the rural areas of this country, and not just in the big urban hospitals. EMS systems were developed. Basic Life Support, Advanced Cardiac Life Support, Advanced Trauma Life Support, Pediatric Life Support, Advanced Pediatric Life Support and Neonatal Life Support Courses were developed and became more available. I remember resuscitating a young lady in 1980 using what I considered standard ACLS protocols; when it proved successful, each nurse from the hospital came down to the department. When I asked my charge nurse what was going on, I was told they had never before had a successful resuscitation here.

Emergency physicians worked hard in the 1980s and 1990s to develop good working relationships with physicians and administrators, as well as patients. Emergency physicians began to do their own research and established trauma registries. We were designated specialists in terms of residencies, but were thought of as generalists on medical staffs. The Emergency Department became the medical safety net for uncared for and underfunded patients. Like other physicians we began looking not just at diagnoses, but began to seek etiologies. We began to work with legislators on efforts to make safer communities for children and the elderly.

In the 1990s, emergency medicine itself began two subspecialties and now in 2006, there are 25 separate sections with the American College of Emergency Physicians. There are 5 subspecialty boards to which Emergency Physicians may apply. Approximately 26,000 physicians are seeing over 200,000,000 emergency visits each year since 2001 in the United States.

Now the emphasis is on protocols, and evidence-based medicine in an effort to achieve "best practices," streamlined emergency medicine, and hopefully better outcomes for more patients. Young physicians, in an effort to rapidly gain competence in an exponentially increasing environment of medical information, use abbreviated texts and handheld computers to check information. However, this has the potential to cost us our wonderful relationships with our patients. While I applaud the efforts to bring less-accomplished physicians up to a baseline of care, formulae can not replace the rapport we need to establish with our patients and their families, and computers can not take the careful histories even the most experienced physicians need to diagnose and treat their patients. An algorithmic approach to medical care alone cannot provide the real personal satisfaction physicians seek from their work. Only the personal satisfaction of helping our neighbors in their times of crisis provides the satisfaction that may compensate us for the long hours of training, the time and distance from our families and the isolation we each feel at times. Nor can algorithms replace the thinking all physicians must do when caring for individual patients. Guidelines are not gold standards and should be considered as works in progress.

The changes I see in emergency medicine are wonderful. I see brighter physicians entering careers in emergency medicine with visions of long careers, rather than the ten years of service which was common in the 1980s. I see self-determined local groups with strong community ties replacing large faceless business alliances. As administrators and physicians learn to work with each other, the trend to simply go for the lowest bid should disappear. Local groups will learn to play to the strengths of their individual physicians while giving them opportunities to grow as individuals. Physicians will be challenged to both lead and educate healthcare teams within and outside of their departments. Physicians will also be challenged to meet increased demands for service that may be met by other health care providers, including physician assistants and nurse practitioners under their direct supervision and training. Triage systems become more and more sophisticated. As medical records become electronic and more standardized, more opportunities will occur for best practice analysis, and even better outcomes may be realized. These positives will continue to be weighed against the threats of frivolous lawsuits that threaten to destroy the informed physician's creativity in medical care. Adhering to protocols alone does not ensure a great outcome. Federal and state legislatures still must address this issue. The other threat to emergency medicine is the growing percentage of unfunded care, which has now reached 60% at my main hospital. While our ethics demand we treat all patients, reality is that we must generate enough funds to have a place in which to treat them. All of this not withstanding, it remains an honor and a privilege to care for our neighbors in their most desperate days.

Friendship is the only cure for hatred, the only guarantee of peace.
--Buddha

Paula Oliver Pell, MD, FACEP, FAAP 

Accepted January 12, 2006.