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Evolution of Emergency Medicine in Pakistan--A Fellow's Perspective.

Dear Editor,

Emergency medicine is a dynamic specialty focused on the rapid identification, evaluation, and treatment of patients who are acutely ill or injured. Due to immense demand, this field has systematically developed and is now offered as structured training in Pakistan. As the first fellow to have attained the reputed fellowship in this field from the College of Physicians and Surgeons of Pakistan, I would like to compare our nation's training program to those of countries where emergency medicine has already been established for almost half of a century. I will also generally discuss this field for newcomers interested in pursuing it as a career.

The American College of Surgeons was among the pioneering groups of physicians that recognized the importance of emergency services. In 1970, the first emergency medicine residency began, and in 1979, the American Board of Medical Specialties recognized it as a forthcoming specialty. Currently, there are now 167 emergency medicine residency training programs that are accredited by the American College of Graduate Medical Education, which offers 1,821 categorical and advanced residency positions. Most programs last for a total duration of three years, but some programs are four years long. There are several combined residency tracks offered as well, with programs like family medicine, internal medicine, and pediatrics. The American Board of Emergency Medicine, which is under the authority of the American Board of Medical Specialties, provides board certification with either the Doctor of Medicine or Doctor of Osteopathic Medicine degrees for licensed practice in the field of emergency medicine. Fellowship training following the completion of emergency medicine residency training programs are available in the fields of sports medicine, pediatric emergency medicine, pre-hospital emergency medical services, disaster medicine, medical toxicology, emergency ultrasound/diagnostic imaging, palliative care, and critical care. The United States is regarded as the best nation in the world to offer training in emergency medicine, and its programs can be very difficult, but not impossible, for international medical graduates to enter, due to a highly competitive selection process.

In the United Kingdom, the equivalent specialty, termed accident and emergency (A&E) medicine, is in a phase of constant and rapid development. By the mid-1970s, it was evident that there was an urgent need to regularize training of consultants for which the Specialist Advisory Committee in A&E medicine was formed and a training program was designed. The first senior registrar induction was in 1977. Following the formation of the Faculty of A&E Medicine in 1993, specialist registrar training in A&E began. As of this writing, A&E is composed of doctors belonging to a variety of ethnic backgrounds in order to fulfill the growing demand and much needed workforce in this field. Training is based on a six-year pathway that begins at the end of the foundation year program. Entry into specialty training for emergency medicine is from the Acute Care Common Stem program, which is a generic program shared by acute medicine and anesthesiology services. The first two years consist of six months of training in emergency medicine, six months in acute medicine, and one year in anesthetics and intensive care. The third year specifically includes six months of training in pediatric emergency medicine. Progression to higher training in the fourth year occurs after a national application procedure. Specialty training between the fourth and sixth years involves 12-month placements in departments of different sizes and patient demographics. The College of Emergency Medicine was founded in 2008 and is now authorized to certify and provide qualification of the fellowship with the Royal College of Emergency Medicine to interested candidates desiring specialization. It is also possible to subspecialize in an area such as pediatric emergency medicine, intensive care medicine, acute medicine, sports medicine, or pre-hospital care.

Our country has adopted a similar Anglo-American model derived from developed nations mentioned before. Emergency medicine in Pakistan is still a very new specialty compared with existing giants such as internal medicine or general surgery. From the time of its creation in 2012, the training program was designed to last five years, thus allowing trainees to experience various rotations and gain the necessary knowledge required in the field. The initial two years involve trainees rotating in specialties like medicine and allied, surgery and allied, pediatrics, anesthesiology, cardiology, and critical care. In the final three years, trainee residents spend their time in the emergency department as seniors who are required to overlook and manage acute presentations. Upon completion of five years, candidates become eligible to sit for the final exam of the fellowship of the College of Physicians and Surgeons of Pakistan. After fulfilling the final requirement, they are awarded the Fellowship in Emergency Medicine.

Emergency medicine is a vast specialty that addresses a variety of medical problems in a way much different from that of any other specialty. It consists of various subjects, each contributing to the pool of knowledge and skill that identifies the specialty. These include the provision of emergency care, teaching and research, pre-hospital medicine, disaster medicine, resuscitation and trauma, toxicology, environmental science, and hospital administration. Emergency medicine provides a "safety net" for the existing health-care system by ensuring that patients have access to unscheduled medical care.

For people interested in pursuing emergency medicine as a career, there is a certain skill set required. Trainees should be able to maintain a fast pace and unending enthusiasm, be involved in working with and leading a team, possess a breadth of knowledge, have effective communication skills, be flexible in terms of working hours, and function well under extreme pressure.

This field offers an exciting, varied, and challenging job that exposes practitioners to all forms of specialties. There is a great deal of practical hands-on work requiring fast judgment and action. Although some may complain that shift work can cause difficulty in maintaining a healthy social life, the number of consultants is expected to increase; therefore, career prospects are great. There are excellent opportunities for covering events, working abroad, and other roles outside of the hospital environment.

What changes will there be to our specialty in the coming 10-15 years? There will be continued increases in demands. There will also be a greater number of patients with more grave illnesses and miraculous expectations. This will also lead to continued pressure on hospital beds. We should make efforts to work with primary care physicians, social workers, and other community services in order to ascertain that the best response to emergency health needs are adequately met. In certain areas, the concept of local urgent care centers will likely become more popular by being able to fulfill most of the health requirements for smaller communities.

Initial patient assessment and immediate treatment during resuscitation of the injured and ill will remain the basic role of the emergency medicine practitioner. If there is a need to look after the health needs of patients for longer periods, then we must begin to develop the skills and experience in order to deal with these issues. We should begin identifying gaps in training and perhaps consider restructuring training programs to ensure that compulsory skills are achieved. It is of equal importance that we realize whether consultants in post need to attain new skill. The system of continuing professional development should identify these gaps, and the necessary financial support must be gained to allow for attaining and retention of new skills.

There is a lot of work that we can do much better than the current system for improving the care for the critically ill. However, we must not forget that focusing on and increasing services to one section of our workload should not decrease services to patients in other departments. Expansion of care requires greater manpower, and neglecting this statement risks overworking current care providers. Emergency departments are struggling to handle increased work demands and are experiencing greater waiting times for patients.

Whatever the future holds, we should strive to remember the reason for our specialty's success: the ability to provide a constant presence at the hospital front door for the many unattended and unannounced emergency health-care needs of patients. Over the last decade, we have been introducing new systems, ensuring that training programs encompass a greater breadth of knowledge and skill, and are more flexible to ensure that new demands are met. Hopefully, with such continued enthusiasm, this specialty will prosper and attain undeniable standing in the health-care system of Pakistan.

DOI: 10.5152/eajem.2017.50570

Muhammad Akbar Baig

Department of Emergency Medicine, Aga Khan University Hospital, Karachi,


Correspondence to: Muhammad Akbar e-mail:

Received: 25.04.2017 * Accepted: 27.04.2017 * Available Online Date: 09.08.2017
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Article Details
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Author:Baig, Muhammad Akbar
Publication:Eurasian Journal of Emergency Medicine
Article Type:Letter to the editor
Date:Dec 1, 2017
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