Hot Topics in EM (a.k.a. Emergency Medicine Issues to Know for Interview Day
As a medical student interested in emergency medicine or preparing for a residency interview, it is critical to have an awareness and basic understanding of hot topics in EM. These topics include the application of new diagnostic and treatment modalities, as well as the business, political, and social forces shaping clinical practice. Here are a few of the most important issues in EM that you should review and understand.
Night Float and Duty Hours
For EMRA's excellent analysis of Duty Hour Restrictions click here.
Emergency Department Crowding
Emergency physicians pride themselves on being the one specialty that will not turn patients away. However, due to a number of factors including a decrease in available inpatient beds, falling reimbursements, and increased emergency department use, EDs around the country are faced with problems of capacity restraints and crowding. Crowded waiting rooms, ambulance diversion, and increases in the number of acutely-ill patients have led to concerns that the quality and safety of patient care are at risk. The emergency medicine literature has numerous peer-reviewed studies and commentaries on this topic that you should review prior to your interview (see Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008 Aug;52(2):126-36). ACEP and other professional organizations also have a wealth of resources available on their websites that provide an excellent overview of the challenges posed by ED crowding as well as the current initiatives being deployed to address crowding. Also see ACEP's work on the issue at https://www.acep.org/content.aspx?id=32050.
Know a few proposed solutions:
- Bedside registration
- Limit triage to what is crucial and bypass triage altogether when beds are available
- Develop a fast track for treating simple fractures, lacerations, sore throat
- Expand the practice of observation medicine - to prevent unnecessary admissions
- Establish clearly defined turnaround-time (TAT) goals
- Use scribes for documentation
- Have all inpatient services managed by hospitalists, and have all ICUs managed by intensivists
The Current State and Future of Emergency Medicine in the United States
The current state of emergency medicine will have an impact on students and residents for years to come. Therefore, it is critical to have an understanding of the future directions that the specialty might take in response to those current issues. Several resources are essential to review in order to better understand this future.
In 2006, the Institute of Medicine issued “The Future of Emergency Care in the United States Health System,” a series of three reports that examine the current state of emergency care in the U.S.,
and present a vision for the future of emergency care. Most notable among the findings of the report is the conclusion that “the nation's emergency medical system as a whole is overburdened, underfunded, highly fragmented…and, ill-prepared to handle surges from disasters such as hurricanes, terrorist attacks, or disease outbreaks.” The IOM report (see www.iom.edu) provides an excellent overview of the history and development of emergency care in the U.S., outlines the tremendous accomplishments in advancing emergency care, and discusses the salient issues and challenges facing emergency medicine in the coming decades. Finally, the report outlines expert recommendations for successfully meeting these challenges.
In addition to the must-read IOM report, ACEP has led a collaborative effort by several organizations to issue “The 2009 National Report Card on the State of Emergency Medicine” (see: http://www.emreportcard.org/). This report provides a comprehensive state-by-state assessment of emergency care in the U.S., and concludes that “the emergency care system in the United States is in serious condition,” with “the overall grade for the nation a C-, and with 90 percent of the states earning mediocre or near-failing grades.” The report card analyzes several areas, including the medical liability environment, access to care, and public health infrastructure and efforts. A review of this report is critical to understanding the atmosphere that exists in those states where you are considering completing your residency training. As such, it is a valuable resource in preparing for interview day.
ACO's and ED Care
Visit ACEP's summary and resources on ACOs at https://www.acep.org/content.aspx?id=78045 . See especially the work of Michael Gerardi, MD, FACEP at https://www.acep.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=78504&libID=78532 and http://journals.lww.com/em-news/Fulltext/2011/04201/The_Ins_and_Outs__and_Upside_Downs__of_ACOs.2.aspx
Role of ACGME Core Competencies in Residency Training
In order to successful complete training and be board-eligible from their respective specialty, all residents must exhibit proficiency in six core competency areas as defined by the ACGME. These core competencies include:
1. Patient Care
2. Medical Knowledge
3. Practice Based Learning and Improvement
4. Systems Based Practice
6. Interpersonal Skills and Communication
Accredited EM residency programs must incorporate these core competencies into residency training and decisions related to accreditation are referred to the Residency Review Committee for Emergency Medicine (RRC-EM).
As you research programs and hit the interview trail, it is useful to review the ACGME guidelines for accreditation of EM residency programs so that you have a foundation for what activities to expect as part of your residency training. These guidelines are available on the ACGME website at: http://www.acgme.org/acWebsite/RRC_110/110_guidelines.asp.
The Emergency Medical Treatment and Active Labor Act is federal legislation enacted in 1996 that governs the actions of any medical facility that receives Medicare compensation. In a nutshell, EMTALA rules state that:
- Treating hospitals and physicians have an obligation to provide a medical screening examination that requires use of ED resources, including specialized tests or consultations.
- Treating hospitals and physicians have an obligation to stabilize patients with identified emergency conditions.
- Treating physicians may transfer a patient if the patient has been stabilized, the patient requires higher-level care, or the patient requests transfer despite neither of the above criteria being met.
- Treating physicians must send pertinent documents, X-ray films, and test results relating to the emergency condition, and they must document the name and location of the receiving physician and facility on appropriate forms.
- If a hospital has patient-care capabilities and resources available to receive a patient from any other hospital in the US, it is required to accept the transferred patient.
- Receiving hospitals or physicians must report to appropriate authorities any transfer received in violation of EMTALA or risk a violation themselves.
- Hospitals or physicians who fail to meet these requirements risk significant fines and penalties.
A major challenge of EMTALA is that the rules are subject to interpretation. For example, what constitutes an "emergency condition" has been extensively debated. At first, the regulations were applied only to patients presenting to the Emergency Department. The courts have a different perspective, and several decisions have held that EMTALA applies to any patient in the hospital.
Ultrasound at the Bedside
- abdominal aortic aneurysms
- pericardial effusions/tamponade
- cardiac activity in pulseless electrical
- ectopic pregnancy algorithms
- intrauterine pregnancy in abdominal
- Deep vein thrombosis
- Abscess detection
- Vascular access
- Foreign body detection
- Pacemaker placement and capture
- Bladder aspiration
- Gestational dating and fetal viability
- Endotracheal tube placement
Resident Work Hours
The long tradition of grueling hours, diverse clinical experiences, and increasing levels of responsibilities for residents has proven to be an important component of medical training. However, there is also strong evidence that fatigue diminishes work performance and learning capacity. The current structure of residency training in the U.S., along with the growing body of literature on fatigue, professional performance, and work-life balance, have led to on-going discussions about resident schedules and the structure of training programs in all specialties. In 2003, the Accreditation Council for Graduate Medical Education (ACGME) issued rules limiting resident work hours. The ACGME rules call for residents to work no more than 80 hours a week averaged over four weeks, and have one day off out of seven averaged over four weeks. They also require a 24-hour limit of on-call duty with an additional six hours allowed for the transfer of patient care. Ten-hour breaks are mandatory between shifts and after in-house call. Residents can have on-call duty no more than every third night, with at least one consecutive 24-hour duty-free period every seven days averaged over four weeks. At-home calls (pages) are not restricted by third night limitations but "must not be so frequent as to preclude rest and reasonable personal time for each resident." In addition to the ACGME guidelines, the Institute of Medicine (IOM) issued a report, “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety,” in December 2008 that suggested further revisions to resident work-hour guidelines. The discussions of resident work hours and residency training program curriculum are likely to continue for the foreseeable future. Therefore, it is necessary for any prospective resident in EM to understand the current rules and any proposed revisions.
Career Satisfaction and Burnout
Emergency physician burnout has been an issue of on-going discussion, with early research on the topic published decades ago. The evidence suggests that burnout among Board-certified EM physicians is no greater than among physicians in other specialties. A recent study on the topic suggested that over half of emergency physicians reported career satisfaction, although concerns about burnout are still substantial (see Ann Emerg Med. 2008 Jun;51(6):714-722). Additionally, burnout is likely to be related to a variety of individual physician factors that help to shape career satisfaction, including opportunities for professional advancement, a flexible schedule, and income potential.
Originally submitted by: Heinz A. Dueffer MSIII, University of Alabama School of Medicine
Chadd K. Kraus, MPH, MSIII
Philadelphia College of Osteopathic Medicine
Editor, Medical Student Governing Council
Steven McGuire, MSIV
EMRA Medical Student Governing Council