Emergency Medicine: The Paradigm Shift

Abstract

Emergency Medicine began as a clinical specialty focused on the provision of pre-hospital and hospital emergency room based care. Fifty years later, it has matured into a new paradigm: it is a complex specialty with a global reach and expansive practice in a variety of geographic and clinical arenas. “E mergency Medicine is a specialty caring for all types of patients, in any place, for any problem, right away, and in the right way .” It is a global population-based specialty, a system of care, has a unique clinical practice compared to other specialties, and is also a management specialty. The curriculum continues to expand to meet community and global needs in a number of areas: emergency pediatric and obstetrical care, emergency critical care, telemedicine, and partnering with public health. The challenges to emergency medicine are global. The most important, and the most pervasive global challenge, is managing stress and burnout which is due to a large number of complex issues. Professional development must be supported and encouraged to produce emergency physicians with cognitive and leadership skills to continue to lead the specialty forward, and to continue to improve the care of the public.

Introduction

Emergency medical care in the 1950’s was a clinical toss-up for the patient. In the US, patients with severe injury would arrive at a hospital in a mortuary hearse as the typical transport vehicle. Hospitals with an ‘emergency room (ER)’ had unsupervised interns or residents providing care. By the 1970’s, the lack of any organized type of emergency care had become part of the national consciousness and was recognized as a true crisis in US medical care. 1

Emergency!

Perhaps by association with the crisis, the NBC television series ‘ Emergency !’ became a staple of US viewing and popularized the concept of emergency care in US society.

The series aired in 1972 and was modeled after the medical and rescue unit of the Los Angeles, California, County Fire Department. In 1971, the US Department of Health, Education, and Welfare provided a grant to the Los Angeles County/University of Southern California Hospital to train residents in emergency care, with 3 residents per year for a 3-year program. In 1973, the US Congress passed the Emergency Medical Services Act 2 , authorizing the development of an emergency medical services system to train health personnel and provide facilities and equipment for a communication and transport system.

Emergency Medicine of Our Founders

The American College of Emergency Physicians (ACEP) was formed in 1968, and by 1973, had 4,000 physician members. The Emergency Medicine Foundation was created as a federal non-profit organization to fund research and educational projects. In 1972, the National Library of Medicine indexed the Journal of the American College of Emergency Physicians (JACEP, now the Annals of Emergency Medicine). In 1979 the American Board of Medical Specialties approved Emergency Medicine as the 23 ^rd specialty. 3

The Ball Started Rolling

The University of Cincinnati began its first emergency medicine residency in 1970. It was an individually developed training program approved by the medical school Dean. The concept grew, and residencies began to proliferate. ACEP developed ‘arms’ to manage the growing pool of programs. The Emergency Medicine Residency Review Committee reviewed the curriculum, education, and training environment, and trainees in approved programs could then apply for American Board of Emergency Medicine (ABEM) certification. In 1977, the ABEM certification exam was field tested, and in 1980 the first validated ABEM certification exam was ready for the new graduate trainees.

Resident training was focused on clinical rotations and a series of lectures and the basic simulation exercises of Advanced Cardiovascular Life Support (ACLS), Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS). Building blocks were initial training in a variety of specialties, such as pediatrics, surgery, anesthesia, cardiology, and intensive care. As training progressed, ER rotation time progressively increased. Clinical teaching and supervision are now the responsibilities of physicians trained in other specialties who had already devoted their careers to full-time or part-time emergency practice. Their knowledge came through experience. Training and practice, however, was limited to the ‘ER’ — the emergency room that would see patients on initial presentation but that would not assume responsibility for any continued patient care.

Fundamentals of scientific inquiry are an essential part of medical training. The research building block was provided by innovative early ER docs who bootstrapped their ideas with researchers in other specialties and were initially focused on cardiopulmonary resuscitation. These research attempts were pre-web, pre-Iphone, pre-Cochrane. But research ideas grew and proliferated. It soon appeared that it was in the ER where common, and uncommon, illnesses, and injuries often first presented, and needed to be studied.

Modern Life

Modern life has propelled the new paradigm of Emergency Medicine. Changes in employment, occupation, marital status, and the digital workplace, have resulted in geographic mobility, leading to a need to find emergency care ‘in the moment’. 4

Medical advances for treatment in the ‘golden hour’ of sepsis, ST-elevation myocardial infarction (STEMI), trauma, and stroke, have resulted in the need for emergency medicine to identify and begin care for time-sensitive conditions, but also to work hand-in-hand with other specialists and sub-specialists. Emergency Medicine physicians are now resuscitation ‘proceduralists’. Everyday EM practice consists of adult and pediatric resuscitation, trauma resuscitation, point-of-care emergency ultrasound, airway control and intubation, IV and IO access, and in some locations, pre-hospital ECMO. 4 , 5 ED visits keep increasing, the Centers for Disease Control and Prevention (CDC) estimate of ED visits for 2022 was the highest volume ever recorded 155.4 million visits! Why? The ED provides excellent service—immediate entry to hospital admission; a growing aging population with high acuity diseases; 60% ED visits outside traditional business hours; availability of every type of specialist 24/7- and despite hallway boarding and waits for care, ED popularity continues to increase. 6

Many adults and children with infection, injury, UTI, community acquired pneumonia, and skin and soft tissue wounds are first seen in the ER. 7 - 11 Traditional specialties focused on hospital-based outcomes of illness and injury and no data was available to guide ER treatment. Hospital-based outcomes are identified by the multiple ICD-codes (International Classification of Diseases, ICD-9 or 10) that are generated for each individual patient, and reflect the patient’s course and diagnoses throughout the hospital experience. ER based encounters are typically based upon ICD codes for signs and symptoms, rather than definitive diagnoses. ER data is extremely useful for syndromic surveillance. Patterns of acute illness, injury, and community risk factors can then be utilized by the public health system, hospital, and community for interventions that improve care. For example, the historic lack of bystander response to cardiac arrest (identified through ER surveillance data), has led to community CPR training and AED installation for bystander use. Thoughtful and innovative emergency medicine groups have thus been organized, using multi-hospital and global data, to create and translate definitive hospital-based diagnostic treatment and research into ED clinical practice. Pediatric Emergency Care Applied Research Network (PECARN) 12 for children, established in 2003, and EMERGEncyIDNET 13 for surveillance and management of acute infections, established in 1995, are two such key groups. Such work solidified the broad scope of diseases that emergency physicians must diagnose and treat, using empiric therapy that is not commonly provided with evidence-based medicine.

The New Paradigm

The ER is now the Emergency Department (ED), with multiple clinical components (triage, fast track or urgent care, acute care, intensive care) and a complex administrative structure that integrates with the larger hospital system and local, regional, and state authorities.

Emergency Medicine is:

A Global Population-Based Specialty

A System of Care

A Unique Clinical Practice

A Management Specialty

A Global Population-Based Specialty

Emergency Medicine is officially recognized as an independent specialty in > 50 countries by the International Federation of Emergency Medicine. 14 Emergency Medicine treats all disorders, all acuities, all ages, any day and any time. There is no target population, no targeted complaint, and all care is unscheduled. The ED provides care when prevention and community resources fail. Unfortunately, for conditions such as domestic violence, sexual abuse and assault, and mental health issues, the emergency department may be the only place to go for care.

Emergency medicine focuses not only on individual care, but also of the needs of groups of people in its communities, regions, and states. The ED reflects the distribution and prevalence of disorders in the community, and globally, ED resources are adjusted to fit community needs. For example, in Japan, the population of those aged > 65 years old was 26.3% in 2018. 15 There is a lack of emergency physicians to staff all EDs in Japan. This has resulted in a sophisticated triage and hospital ED system which directs patients > 65 years old to primary, secondary, or tertiary emergency care hospitals. In the US, a surge in ED opioid visits led to the initiation of buprenorphine treatment in the ED, and the provision of buprenorphine prescriptions at discharge. 16 The Emergency Medicine Education and Research by Global Experts (EMERGE) Network has collaborations with 26 EDs in 17 countries, to translate knowledge and improve emergency care for patient populations. 17

A System of Care

Emergency Medicine as a system is composed of a set of organized health care professionals working under the leadership of emergency physicians who are trained to manage the system. The health professional set includes physicians, nurses, advanced care providers (nurse practitioner or physician assistant), EMTs, paramedics, and first responders. The system of care begins in the prehospital setting and continues through ED care and patient disposition. The system requires communication and collaboration with hospitals to provide adequate staffing and equipment to care for a variety of complaints. Support from hospitals, medical schools, and community colleges is necessary to train the emergency health professionals.

The emergency system of care requires emergency physician leadership to insure collaboration of care from the prehospital to ED with appropriate specialists and services. But such systems do not develop in a vacuum. Emergency Medicine leaders are key in the development of legislative and state support needed to develop sophisticated hospital services for stroke and STEMI; trauma systems; and poison control centers. Systems for disaster preparedness and management are complex and require an incident command system to maintain collaboration between fire, police, specialists to manage different environmental and physical hazards, and the ED ability to handle mass casualties.

A Unique Clinical Practice

Emergency Medicine is the only specialty that treats large volumes of patients, with different acuity levels and different complaints, simultaneously. Whether the situation is ED overcrowding, ED boarding, multiple patients with time-sensitive or complex care needs, or the influx of large numbers of patients during a mass casualty event – emergency physicians must provide a rapid diagnosis and begin empiric and stabilizing treatment with a minimum of data and within minutes of the patient encounter.

Emergency physicians require specific physical and cognitive skills to practice in a high-intensity environment. 18 It is a physical specialty, with a busy shift requiring walking about 2.6 miles. 19 Working shifts vary in length of shifts (8–24 h depending on the ED), and time of day (days, afternoons, and midnights), and energy and cognition must be maintained despite these variations. Emergency physicians must adapt to task-switching between patients and nursing staff, with interruptions to review ECGs, talk to consultants, answer the phone—as examples of switching activities unique to the ED.

The first step in the decision-making process in Emergency Medicine begins a series of steps and is initially based on pattern recognition. Identifying the chief complaint is the first step- this is accomplished at triage and verified at the initial physician-patient encounter to identify acute life/limb threats. Assembling cognitive knowledge from lectures, conferences, journal clubs, and asynchronous learning, and prior practice experience, the next step is associating important signs, symptoms, and associations to begin diagnostic studies and provide empiric initial stabilization and treatment. Further steps depend upon the results of response to treatment, diagnostic studies, review of medical records, and at this point moves to the typical deductive reason utilized by other specialties. Often, a specific diagnosis is not possible in the ED, but treatment is based upon a symptom complex: chest pain, sepsis, heart failure. These steps of care are impacted by the amount of concrete data available at each step. Treatment must move forward, despite diagnostic uncertainty. Unfortunately, reports of ‘diagnostic error’ as a unique attribute of emergency medical care 20 are an erroneous conclusion, and reflect a lack of understanding about the ED environment and ED decision making.

A Management Specialty

Much of the initial concern about emergency medicine arose from the concept that much about emergency medicine was not clinically distinct but more akin to management.

In fact, that is true, and in today’s complex and global society, good management is a key to providing good clinical care with an efficient and capable department. Good management is even the key to running a good shift. 21 Management in the emergency medicine system includes many components: decision-making; planning, organizing, directing ED services; preparing budgets; supervising billing; recruiting, training, scheduling staff; teamwork; developing policies and procedures; and ensuring that the ED operations fit with the goals and abilities of the healthcare system in which the ED operates.

Emergency Medicine has always used business models because EDs were typically viewed as ‘loss leaders’ for a hospital. The ED is not a typical ‘loss leader’ in the business sense, but has similar features. In the US, payment is not required before ED care is given. In general, the cost of ED care greatly exceeds hospital revenue. Reasons are complex and include use of the ED by un-insured or under-insured patients. Hospitals typically view the ED as its own ‘cost-center’, which includes payment for ED physicians and nurses, specialty emergency services (Trauma), and support personnel on a 24-7 basis. The ‘cost center’ approach continues despite many accurate reports that the ED (by providing 30%–70% of hospital admissions) is the gateway for profitable surgery, complex care, and outpatient services. 22 , 23 Historically, reimbursement and hospital financial support for ED care was typically lacking, or if present, was minimal. This is still the case in many parts of the world. Interns were typically free hires to work in the ED. Emergency Medicine had to develop business models to pay for hiring emergency physicians as faculty to work and train residents, and to demonstrate to the hospital that training emergency physicians would provide a pool for future benefit.

A Paradigm for the Future

Emergency Medicine should, and can, expand knowledge and skills to enhance its scope and to continue to benefit the healthcare of the population. Areas prime for development include curriculum expansion to areas outside the academic center; improving emergency pediatrics, obstetrics, and critical care training; providing telehealth experience; and collaborating with public health.

Curriculum Expansion

Most resident training is accomplished in an academic center. There are many benefits: teaching and learning from specialists and subspecialists; plentiful personnel for assistance (trauma team, pediatricians for neonatal resuscitation); newest equipment; collaboration in research; experts available for data management and analysis.

Academic training has its limitations: zebra diseases; competition for procedures with other specialty trainees (chest tube, central line insertion); insufficient exposure to common but minor conditions); training for learning, not for value-based care. Academic institutions and departments tend to have silo-driven practices, often with good reason because of the complexity of focused diagnostics, therapeutics, and rehabilitation. The ED is too often a place where silos must be crossed.

For example, when a trainee is assigned a month obstetrics rotation, the routine steps of a difficult delivery, shoulder dystocia, or cord prolapse are mentally rehearsed, memorized, and perhaps even practiced. The diagnostic experience with pediatric fever is similar during a pediatric assignment. A general ED experience must cross these silos, mentally, clinically, and sometimes with the speed of light. A clear goal in resident training should be the ability to practice in community, rural, or underserved areas such as Indian or Aboriginal areas. 24 Specialist services in underserved areas can be somewhat mediated by telehealth consultation, especially in areas like emergency pediatrics. Rural hospitals are often primary providers of healthcare services with few specialists available, and also provide opportunities to engage in community health improvement. 25 Such rotations increase trainee interest to work in rural areas. Multidimensional strategies in a variety of countries (Norway, Australia, US, Brazil) which include government financial support for training and practice in rural areas have had positive results. 25

Emergency Pediatrics and Emergency Obstetrics

Pediatric Unit closures and low volumes of pediatric patients in some EDs have resulted in knowledge and practice gaps in pediatric care. Errors in diagnosis are greater in EDs that see low volumes of pediatric patients compared to those EDs that see larger volumes. 26 One small survey 27 reported a 60% error rate in ED pediatric diagnoses, based upon misinterpretation/ignoring history, or performing an incomplete pediatric examination. Pediatric Emergency Medicine (PEM) subspecialty training is certified both by the American Board of Pediatrics and the ABEM, and 99% of certified PEM physicians 28 gravitate to urban tertiary care EDs with large pediatric volumes. The nuances of pediatric care, especially in the neonate and in infants, require better training and experience than is currently provided in the usual pediatric and emergency medicine training programs.

Emergency Obstetrics care training suffers from disadvantages similar to Emergency Pediatrics. The closure of obstetrics units in rural and community hospitals has resulted from low volume, low practice experience, difficulties in skill maintenance, challenges in recruitment, and financial instability. Prehospital and ED obstetric emergencies are often high-risk—out-of-hospital delivery; multiple gestation delivery; prolapsed cord; non-cephalic presentation; and shoulder dystocia. 29 , 30 The closure of obstetric units has led to presentation of obstetric emergencies to EDs, where emergency physicians have had little exposure to obstetrical emergencies since the first year of residency training. The Helping Babies Breathe (HBB) 31 and Advanced Life Support in Obstetrics (ALSO) 32 were developed to improve care in underserved global regions. However, emergency physicians and EM residents are often uncomfortable managing obstetric conditions without an obstetrician at the bedside, and would benefit from continued training and retraining as is offered by HBB and ALSO. 33

Critical Care: The Sooner the Better

Prolonged boarding in the ED with critically ill patients leads to worse clinical outcomes. Some hospitals have developed ED Critical Care Units 34 , and others have restructured the responsibilities of critical care physicians to provide direct assistance to critical care patients boarded in the ED. 35 Basic prerequisites for ED Critical Care subunits include: tools to recognize critically ill patients early and prioritize their needs; sufficient staff trained and experienced in the management of critically ill patients; a dedicated resuscitation and critical care area; evidence-based protocols, and quality indicators to follow clinical outcomes of critically ill patients in the ED.

TeleHealth and Emergency Medicine

Telehealth accelerated dramatically with the COVID-19 epidemic, even though telehealth had already been used successfully in critical care access hospitals 36 and in natural disasters. During the 2024 Hurricane Helene devastation of western North Carolina (NC), NC tertiary care centers and Teladoc Health (teladochealth.com) provided free virtual care to impacted communities and individuals. The North Carolina Medicaid program lifted many administrative and practical restrictions to care, including early prescription renewal, home medication delivery, provision of medically necessary services, and adjustments for personal care. The NC Medical Board activated a Limited Emergency Licensure for out of state physicians to provide care, including use of Telehealth. Telehealth is an efficient method for virtual patient care for those who lack easy access to primary care providers and can provide care without the inefficiencies that accompany clinic visits. Telehealth systems are a natural for emergency physicians, who are familiar with, and competent in, providing care with a minimum of data. 37 Telehealth education must be incorporated into medical student and emergency medicine resident training and practice, to learn communication skills, policies, procedures, and benefits. 38 Emergency Pediatric Telemedicine systems are another opportunity for the provision of real-time pediatric expertise to general emergency physicians. 39

Partner With Public Health

Emergency Medicine has the skills, scope, widespread national and global presence, and influence, to improve the health of the public. Emergency visits continue to increase: the 2022 estimate is > 155 million ED visits in the US. 6 , 40 EM is skilled at health messaging in the ED environment. Encouraging patients to stop smoking, assessing readiness for alcohol and drug cessation, arranging situational and psychological care for domestic violence and child maltreatment, providing car seats for those in need, and encouraging use of helmets during biking/cycling, are some examples. Emergency medicine is on the front lines of population care and can detect health threats early through syndromic surveillance. 88% of emergency departments in US do syndromic surveillance and monitor usual and unusual trends. 41 The ED is on the front lines of many disorders including pandemic respiratory illness, emerging infectious diseases, overdoses, acute geriatric care, acute mental health problems, domestic violence, and sexual abuse/assault. There is much room for global cooperation with public health, hospitals, and EDs.

A recent survey of health professionals working in 148 European EDs reported that only half of the hospitals surveyed had policies and protocols addressing the care of maltreated children. 42 Improvements will lead to improved ED, community, and hospital interventions. An innovative intervention in bleeding control was developed in Tanzania. 43 Death rates from traffic accidents are twice the global rate. A set of motorcycle taxi drivers were trained by medical students in basic hemorrhage control. During the study period, one-third of the motorcycle taxi drivers were able to institute proper hemorrhage control until definitive care arrived or until the patients were transported by taxi to the hospital. Emergency physicians are the key to addressing public health needs such as those described above.

Challenges

Research and Development: Emergency Medicine Must Fill in the Gaps

The growing volume of patients in EDs with all types of general and specialty problems, and the health threats posed by cross-border conflict and immigration are a cry to the future for expansion of emergency medicine beyond the clinical arena, and into the research arena. Support for such innovation must be derived from national and global constituencies, emergency medicine societies, and independent and institutional foundations. Read below for innovative programs, but remember the Moral Of These Stories: research and innovation begin at our home institutions with our home faculty mentors, and Department of Emergency Department support!

The UK James Lind Alliance (JLA)—EM Priority Setting Partnership Steering Group expanded its emergency medicine research priorities to include 44 : care of frail elderly trauma patients; acute head injuries; acute low back pain, biomarkers in sepsis; optimize care for mental health patients; role of ED in end-of-life care; prioritize care while reducing harms of ED overcrowding; acute aortic syndromes; and improvement of work-life balance in ED health care.

The US Emergency Medicine Foundation, through its individual donors, societies, and corporate partners has provided research development grant support in 2024–2025 to 21 individuals, with the following selected list of innovative research topics: ‘Impact of ED Group Ownership on Market Structure, Care Patterns, and Patients’; ‘Defining Diagnostic Excellence for Emergency Medicine and Establishing Research Priorities’; ‘Unraveling Molecular Mechanisms of Cerebral Edema after TBI using Non-Invasive Brain Cell Type Specific Gene Silencing’; ‘Monitoring Peripheral Tissue Perfusion using Diffuse Correlation Spectroscopy (DCS) in patients with Sepsis; and Using Artificial Intelligence to Identify Undiagnosed Structural Heart Disease in the Emergency Department. For a full list of the awardees go to website: www.emfoundation.org.

The European Commission’s Health Emergency Preparedness and Response Authority (HERA) has a number of funding opportunities focused on cross-border threats, through Horizon Europe and rescEU.

A number of individual US academic emergency departments with dedicated research sections also provide research stipends, mentoring, and sponsorship for talented and innovative residents and faculty.

The National Institute of Neurological Disorders and Stroke recently introduced a new program, the Emergency Medicine Research Career Development Program in Neurological Sciences (EMRCDP-NS) using the K12 mechanism, to advance the understanding and treatment of neurological disorders commonly seen in the ED.

Stress and Burnout: A Global Challenge

In the US in 2020, 50% of emergency care workers reported burnout, and 29% intended to leave their position. 45 Similar findings have been reported globally, with numerous factors contributing to burnout. 46

The basic structure of the ED environment itself is stressful. ED overcrowding, boarding, and the need to see everyone immediately, are worsening problems that affect all EDs. Shortages of ED nursing staff and ancillary personnel (which began with the COVID-19 epidemic) continue to plague the ED environment. 47

One of the most concerning factors affecting the global ED environment is the seemingly growing amount of physical, verbal, and emotional abuse and violence suffered by health care personnel. 48 , 49 However, the solutions are complex. The Canadian Center for Occupational Health and Safety, and the European Society of Emergency Medicine have proposed multiple strategies for violence mediation, including written policies; reporting and encouraging reporting of abuse and violence; legislation; improving safety of the working space; management and prevention techniques to prevent violent incidents. The institution must demonstrate the application of a variety of techniques, and demonstrate a decrease in the abusive/violent episodes, in order to maintain staff interest and enthusiasm to participate, and decrease burnout. 48 - 50

Professional Development and Advanced Degrees

Emergency Medicine is a career for a lifetime. The physical and emotional stresses of emergency medicine practice cannot be sustained forever. Promotion in a hospital or academic institution requires many components for a strong portfolio: clinical expertise, research, education, and service and leadership. The promotion process for a clinician who devotes most professional time to clinical care and clinical teaching is difficult and complex. Promotion requires an organized approach and solid support from the emergency medicine and institutional leadership, and from related professional organizations. 51 , 52

Advanced degrees, such as the MPH, MBA, can be important tools for career advancement. Carr and Topol 53 have very recently advocated for a Master of Digital Health Degree, modeled after the Master of Public Health degree, focusing on AI, data integration, and technology driven models. Such advanced degrees can result in networks for communication and experience and provide a focus for specialized expertise that can result in promotion or career expansion.

Service on committees within the home institution or in the organizations of Emergency Medicine are important ways for a career emergency physician to learn leadership and negotiating techniques. Service on cross-functional hospital teams is a good method to practice and learn to work with others.

Emergency Medicine has developed strong fellowship opportunities and many fellowships lead to specific certification and career expansion. Pediatric Emergency Medicine, Toxicology, Hyperbaric and Undersea Medicine, Palliative Care, Forensic Medicine, Critical Care, Wilderness Medicine, and Health Informatics are popular examples. Advanced Emergency Medicine Ultrasonography 54 , the first emergency medicine area of Focused Practice Designation, was issued in 2022.

Summary

Emergency Medicine has evolved over 50 years from a specialty limited to clinical practice in the Emergency Room of a local hospital, to recognition as a thriving national specialty in > 50 countries. It has evolved into a new paradigm: a global population based specialty; a system of care extending from the prehospital, hospital, and community environments, to practices in geographically dispersed areas; to care for specific health issues with emergency implications; and has continued its maturation as a management specialty.