CONCEPTS, COMPONENTS & CONFIGURATIONS emergency medicine, department status
Autonomous Departments of Emergency Medicine in Contemporary Academic Medical Centers There are currently 20 autonomous departments of emergency medicine in United States medical schools. EDs seeking autonomous status should institute a faculty development program to channel faculty energy into worthwhile research projects; establish protected time for clinical faculty to increase research productivity; develop expertise to compete for extramural funding; initiate an intramural research program so that faculty can learn the basics of grantsmanship; teach health care issues in ambulatory medicine; become involved in interdisciplinary teaching programs and curriculum development; maintain the present faculty c o m m i t m e n t to 24hour attending coverage; and develop university-based programs that originate from the ED. Program directors should establish liaisons with the medical school dean to acquaint him with the advantages of an autonomous department of emergency medicine; attempt to assess other relationships within the medical school to determine support for emergency medicine and to uncover and address opposition to autonomous departmental status; attempt to serve on medical school committees to meet other faculty, solve problems with them and develop trusting relationships; and develop broad-based support for autonomous departmental status both within and outside of the university. By devising and following a deliberate approach to attaining departmental status, emergency medicine will be assured of continued growth in the important decade ahead. [Rusnak RA, Hamilton GC, Allison EJ Jr: Autonomous departments of emergency medicine in contemporary academic medical centers. Ann Emerg Med June 1991;20:680-687.]
INTRODUCTION With the September 1989 vote by the American Board of Medical Specialties to approve primary board certification for emergency medicine, our specialty has been granted de facto recognition of its important place in contemporary American medicine. Hence now is an appropriate time to increase our efforts to win wider acceptance for our specialty within academic medical centers. Since its inception in 1968, the specialty of emergency medicine has matured along several lines. First, emergency medicine has greatly improved the quality of patient care in emergency departments while simultaneously treating a steadily growing patient population. Second, residency training programs have been developed. Third, a superlative specialty examination process has been created. Fourth, a research base unique to our discipline has developed and is expanding. The next important task is to elevate our specialty's standing through a concentrated effort to establish autonomous departments of emergency medicine within our medical schools. Currently, there are 20 autonomous academic departments of emergency medicine in US medical schools. The tal~le lists these departments and indicates the factors that were critical in their establishment. Many were created in the early 1970s, in response to such circumstances as the approval of an emergency medicine residency training program, the salvaging of an ED experiencing clinical service problems, or as a pre-employment agreement with an individual being recruited for the faculty. In the last decade, however, emergency medicine has realized that a more systematic approach is necessary to secure its
20:6 June 1991
Annals of Emergency Medicine
Robert A Rusnak, MD* Minneapolis, Minnesota Glenn C Hamilton, MD~ Dayton, Ohio E Jackson Allison Jr, MD, FACEP* Greenville, North Carolina From the Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota;* the Department of Emergency Medicine, Wright State University, Dayton, Ohio;~ and the Department of Emergency Medicine, East Carolina University, Greenville, North Carolina.* Received for publication July 3, 1990. Revision received December 3, 1990. Accepted for publication December 28, 1990. This paper was written under the auspices of the Association of Academic Chairs of Emergency Medicine and the Society for Academic Emergency Medicine. Address for reprints: Robert A Rusnak, MD, Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, Minnesota 55415.
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AUTONOMOUS DEPARTMENTS Rusnak, Hamilton & Allison
place within academe. Before embarking on the long and arduous journey toward autonomous departmental status, the emergency physician who will be driving the process must understand the values of the institution in which the emergency medicine program finds itself. These values usually revolve around the specific "weighting" or credits given for research, service, education, administration, financial contribution, and longevity by the institution. The institution will grant the request for autonomous departmental status only if the capabilities and status of e m e r g e n c y medicine are c o n s i s t e n t w i t h the i n s t i t u t i o n ' s values and will further its goals. If this is not the case, the process may be doomed before it starts. Although it is possible to change the value system of an institution, this task is n o t o r i o u s l y difficult. Most basic changes in a c a d e m i c medical centers have occurred due to the influence of powerful external (eg, the state or federal government) or internal (eg, the medical school dean or the vice-president for health affairs) forces. It is doubtful that an emergency medicine residency training program director acting alone can effect this change. If the institution's values are incompatible with autono ~ mous departmental status for emergency medicine, knowing this at the outset can allow one to avoid frustration and adjust one's ambitions. Under these circumstances, the emergency medicine program director's choices are to scale down the objective (eg, to divisional status or to simple survival of the program) or to leave the organization. To d i s c o v e r the i n s t i t u t i o n ' s values, one should hold discussions with at least three key people: the dean, the chairperson or a cooperative member of the promotions and tenure c o m m i t t e e , and a f a c u l t y member who is successful in the system, yet is allied to emergency medicine's ambitions. Ideally, one or more of the three will later assist in mentoring emergency medicine through the process. The questions to be asked are simple. What does the institution value? How do its values translate into the criteria for promotion and tenure? What actions can the emergency medicine program take that will be consistent with the institution's values? Are there ex120/681
plicit and implicit values within the medical school, and what are their differences? (This last question is best reserved for the individual(s] willing to act as a mentor; asking the wrong parties risks backlash and misinformation.) Once this system is well understood and the values of emergency medicine are seen to coincide w i t h t h o s e of the m e d i c a l school, one can undertake a course toward autonomy, confident of the emergency medicine request's chances for success. In addition to assessing the value s y s t e m of the m e d i c a l school in which the emergency medicine training program wishes to establish an a u t o n o m o u s d e p a r t m e n t of emergency medicine, it is also important to bring to the fore the benefits to be gained from a successful effort. In this way, the emergency medicine training program can weigh the costs and benefits of the considerable effort to be expended during this process to help decide whether an autono m o u s d e p a r t m e n t of e m e r g e n c y medicine is desirable. The p r i m a r y v a l u e of m e d i c a l school affiliation as an autonomous d e p a r t m e n t is influence over the forces that shape the destiny and direction of an emergency medicine training program within the medical school hierarchy. This power resides in three areas: the power of space allocation within the institution; the power to r e c o m m e n d faculty and staff appointments~ and influence over financial resource allocation. As a departmental chairman, an individual will also have the opportunity to appoint faculty or become a member of i n t r a d e p a r t m e n t a l c o m m i t t e e s within the university. These committees should include the following: the C o m m i t t e e of Chairmen; the Dean's Special Committee (also referred to as the Dean's Advisory Committee); the Committee of Clinical Chairmen (usually formed outside the Dean's control in w h i c h m e m b e r s discuss the direction of their own clinical and collective services); and the Faculty Practice Committee. After careful consideration of the benefits to be gained and the sacrifices necessary to achieve autonomous d e p a r t m e n t a l status, emergency medicine training programs will be in a position to decide on an approach for achieving that status. In Annals of Emergency Medicine
this way, when negotiations begin, emergency medicine programs will know what they are willing to sacrifice to achieve autonomous departmental status. In this article, it is assumed that academic emergency medicine departments have a legitimate place within medical schools. Emergency m e d i c i n e r e s i d e n c y t r a i n i n g programs that do not yet enjoy autonomous department status are offered suggestions for attaining such status. Two basic areas of work are discussed: that done within the EM residency training program and that done between the program and the medical school in which it is seeking autonomous department status. The former includes a program for faculty development and programs intended to improve the productivity and prom o t a b i l i t y of c u r r e n t e m e r g e n c y medicine faculty, mindful of an institution's value system for research, teaching, and service. The latter includes the nurturing of a mutually respectful relationship with the medical school dean, discussions with department and committee chairs, and greater participation in medical school instructional programs. This article proposes a strategy for the important decade to come, a decade in which we anticipate that emergency medicine will succeed in its efforts to be fully recognized within each medical school in the United States.
WORK WITHIN THE EMERGENCY MEDICINE RESIDENCY TRAINING PROGRAM Traditionally, the academic promotion of an individual is based on research, teaching, and service (eg, patient care or administration). It follows that improving the promotion credentials of individual faculty will improve the credentials of the program seeking a u t o n o m o u s department status. This section focuses on improving the prospective department's promotability to demonstrate compliance with the rigorous standards expected of an autonomous department. As mentioned earlier, understanding the promotion pathway is an important means of understanding the institution's value system.
Faculty Development Research and publication are two very important academic activities. 20:6 June 1991
AUTONOMOUS DEPARTMENTS Rusnak, Hamilton & Allison
The unique skills required for success in these areas, however, often require coaching. A program will benefit greatly by appointing an experienced research director (MD or PhD) who can serve as an advisor for less experienced faculty and can generally channel faculty energy into promising areas of investigation. If, as we hope, our specialty society develops liaisons with the organized research community in the United States, and assuming that the network within academic emergency medicine continues to grow (eg, the Society for Academic Emergency Medicine), the research director would serve as the program's chief contact person for keeping abreast of new developments in the field and would encourage less experienced faculty to pursue fundable research projects. This individual will serve best if given the opportunity to lead by example. A faculty development plan should allow time for teaching the skills needed to write research papers and grant applications or the emergency medicine program should establish access to this expertise. The program should also strive to engage in joint research projects that involve experienced grant writers within or outside the institution. "Riding the coattails" of an experienced investigator is an important traditional, apprentice method of learning research and grantsmanship.
Research At present, the foremost promotion criteria at research universities is original, credible research and p e e r - r e v i e w e d p u b l i c a t i o n . Such work is essential for both individual faculty and the program as a whole. Due to its obvious relationship to research and publication, the procurement of extramural funding is also important; an established history in this area adds significant support to the emergency medicine program's request for autonomous departmental status. For clinical faculty within medical schools, there has been a shift in the criteria for m e d i c a l school advancement. As service demands have increased, retention of skilled h e a l t h care providers and teachers has become critical. Some i n s t i t u t i o n s (eg, Harvard Medical School) have therefore increased the time allowed for clinical faculty to demonstrate research productivity 20:6:June1991
from seven to nine years. This trend works to the advantage of a specialty with high clinical service demands (eg, emergency medicine) by allowing more time for research and academic development and thereby increasing the probability of advancement.
Teaching Programs applying for autonomous departmental status must also establish and document a history of excellent teaching of medical students and residents in and outside of the emergency departments. EDs that are part of academic medical centers have patient populations that provide an ideal setting for hands-on teaching in the evaluative, procedural, and diagnostic skills needed by all physicians. Outside academic medical centers, community hospital EDs have caseloads that are often large and are comprised of diverse patient populations; these settings are also well suited to teaching and research3 Many c o m m u n i t y hospitals associated with academic medical centers are i m p o r t a n t sites of r e s i d e n c y training. This need will only increase as academic medical center inpatient populations decrease and these centers look to other places for the patients required to maintain their undergraduate and graduate teaching programs. The major teaching effort should be directed toward medical students. At a minimum, freshmen and sophomores need instruction in basic life support. Juniors and seniors benefit from instruction in advanced cardiac life support, and rotations in the ED often give students their first opportunity to perform an evaluation on patients with unselected complaints. The opportunity for such basic procedures as IV access and simple minor wound care is unsurpassed in the ED. W h e n the c u r r i c u l u m is thoughtfully designed and enthusiastically delivered, these students often rate their ED rotation as their best training experience in medical school. For both graduate and undergraduate students of medicine, the ED is an ideal place to teach subjects such as acute care medicine, trauma resuscitation, minor surgery, pediatrics, obstetrics and gynecology, ambulatory care, and the basics of radiology and forensic medicine. The ED is also a natural setting for instruction Annals of Emergency Medicine
in the social issues in medicine, such as care of the poor and indigent, access to treatment, appropriateness of treatment (including cost effectiveness}, rationing and resource allocation, and biomedical ethics. The ED also provides opportunities for students to learn in areas closely related to medicine, such as epidemiology, public health, and health education. Emergency medicine faculty should also take an active role in interdisciplinary teaching and curriculum development. Emergency medicine faculty can teach or be involved in courses that provide clinical correlations for diseases taught in the basic sciences, courses in clinical problem-solving, introductory courses in clinical laboratory medicine, and p h y s i c a l e x a m i n a t i o n courses.
Emergency medicine program directors should tally the data on the total number of medical students, interns, and residents taught each year. Programs should also tally the data on other educational activities such as m e d i c a l s c h o o l c o u r s e s and courses in advanced trauma and cardiac life support. Also included here are postgraduate continuing medical education programs presented during hospital conferences and presentations at state and national meetings. Evaluation is integral to this process; faculty with teaching excellence s h o u l d be recognized, especially those with national or international reputations.
Service The third component in a successful strategy for a u t o n o m o u s academic department status is a demonstrable commitment to excellence in serving patients in the community outside the academic medical center. Through their commitment to provide 24-hour ED coverage, thus ensuring constant access to high-quality care, emergency medicine faculty already fulfill a significant service function. In addition to their continuous presence in the ED, emergency medicine faculty also involve other specialists in patient care, thereby integrating themselves and their program into the fabric of the academic medical center. There are numerous other ways for emergency medicine faculty to contribute to their program's commitment to service. They can serve as 682/121
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TABLE. Autonomous departments of emergency nledicine
Medical School
Date of Department Formation 1971
Dean
University of Louisville
1971
Dean
University of MissouriKansas City School of Medicine Wright State University
1972
Dean, medical school administrative structure
1980
Dean
East Carolina University
1980
Dean
Charles Drew Medical School
1981
Chair of surgery
Loma Linda School of Medicine George Washington University Medical College of Pennsylvania
1982
Dean, hospital administrator Dean, faculty senate
1984
Chair of surgery lobbied support from other departmental chairs
University of Cincinnati
1984
Dean
Albany Medical School
1986
Georgetown University
1986
Dean; medical director of institutional faculty practice plan Chair of surgery knew and trusted chair of emergency medicine
Northwestern Ohio Universities College of Medicine
1986
Emergency physicians in multiple local teaching hospital; academic chairs supportive of emergency medicine
medical directors of ambulance services, helicopter services, emergency medical services training programs, city fire and police departments, and statewide poison control networks; they can sit on disaster p l a n n i n g boards and the boards of state and national emergency medicine service councils; they can become politically active in such areas as handgun control, mandatory seat belt use, and helmet legislation. Emergency medicine program directors should plan the involvement of emergency medicine faculty in these and other areas and incorporate this faculty participation as focus areas for ongoing de122/683
-
1990
Significant Support Factors Considered Important During Deliberations to Form Within Medical School New Autonomous Department
University ot Southern California
1984
-
Chief negotiated department status prior to accepting position; teaching (medical students); emergency medical services activity; separate budget; research credentials of faculty; clinical reputation; chair principal investigator of Health Education and Welfare grant for training emergency medicine residents and quality assurance. Chair reorganizeddistressed department, procured emergency medical services grant money, negotiated departmentstatus prior to accepting position. Emergency medicine a separate hospital departmentand when medical school was formed in 1970, the medical school adopted hospital department structure as medical school department structure. Prearrangementwith dean based on developmentof residency program, student education, and level of scholarly activity. Medical school intent to bolster teaching in family practice and primary care; chair negotiated departmental status prior to accepting position. Clinical service (70% hospital admissions through ED); establishment ol emergency medicine residency; Hearth, Education and Wetfare grant procured by emergencymedicine for emergency medical services; previous difficulty retaining faculty Clinical service issues and equitable agreementsbetween surgery, medicine, and pediatrics. Protecting hospital against liability: clinical service; residency training program, medical student teaching; continuing medical education courses by emergency medicine. High-quality clinical service; large emergency medicine residency training program, emergency medicine part of medical school curriculum; teachingl publications; presence of faculty in national organizations;division of department o1 surgery for 12 years before achieving autonomous status. Chair negotiated departmentalstatus prior to accepting position (freestanding division of Dean's office before achieving autonomous status); research; publications; extramural funding; clinical skills of faculty; commitment to teaching; emergencymedicine residency training. Chief negotiated departmentalstatus prior to accepting position. New department would solve clinical service problems, improve patient care, enhance revenue, improve resident, faculty recruiting. Physical separation of ED from internal medicine; no negative effect on internal medicine; residency training programs and board certification examinationsseparate from internal medicine; improvement in faculty recruitment; teaching achievements; potential to enhance national reputation in emergencymedicine; community involvement. Presence of two weft-establishedemergencymedicine residency programs; medical student teaching; faculty involved in medical school instructional programs.
p a r t m e n t a l research and development of position papers, review articles, and educational p r o g r a m s to ensure academic medical center recognition of efforts in these areas. Also, it is advantageous for emergency medicine programs to develop university-based programs that originate from the ED. Steps to enhance the visibility and status of the university {and emergency medicine within the university) include assuming the medical directorship of a university hyperbaric facility, directing a university or statewide helicopter a m b u l a n c e service, administering a rural.mediAnnals of Emergency Medicine
cine outreach program, and developing a statewide program to improve trauma care.
Growth of the Research Base in Emergency Medicine Establishing faculty development programs in emergency medicine residency training programs and enhancing the promotion credentials of faculty will heighten the status of individual residency training programs in emergency medicine and will also contribute to the growth of the specialty. To foster the growth of a specialty-wide research base in emergency medicine, residency training 20:6 June 1991
AUTONOMOUS DEPARTMENTS Rusnak, Hamilton & Allison
TABLE. A u t o n o m o u s d e p a r t m e n t s of e m e r g e n c y m e d i c i n e - 1990 (continued)
Medical School
Date of Department SignificantSupport Factors Considered Important During Deliberations to Form Formation Within Medical School New Autonomous Department
Medical College of Pennsylvania AJiegheny Campus Bowman Gray School of Medicine Ohio State University
1988
State University of New York-Stonybrook
1990
Texas Tech University
1990
University of North Carolina-ChapelHill
1990
Wayne State University
1990
-
Association of Allegheny General Hospital with Medical College of Pennsylvania;because emergency medicine was already an autonomous departmentat the Philadelphia campus, Allegheny followed same course; functionally a division of departmentof surgery Medical school reorganizationof department of surgery.
1989
Chair of surgery
1990
Dean, former chairs of surgery, preventive medicine, internal medicine Dean
Dean, hospital administration, department of surgery Dean, medical school and hospital administration Dean, chair of surgery
Emergency medicine curriculum in medical school (1st year and elective 4th year); excellent clinical service; research base in emergency medicine; establishment of an autonomous department would facilitate Residency Review Committee approval for emergency medicine residency training program, initially an independentprogram administered by dean. Medical student teaching; patient care in ED; emergencymedical services leadership; initiation of a research base in emergencymedicine; establishment of an autonomous department would facilitate Residency Review Committee approval for emergency medicine residency training program, initially an independentprogram administered by dean. Cfinical service; physical separation from other departments of medical school (based in Lubbock); faculty retention; developmentof residency. Attending coverage in ED for problem solving and quality assurance. Funding from hospital administration and medical school; developmentof emergency medicine residency; improved administrative organization of ED. Incoming chief asked dean to develop criteria for formation of a new departmentthat developed along with those suggested by dean, including high-quality clinical service; development of excellent faculty; well-trained residents and students; scholarly activity reflected by grants and publications.
Medical School AffiliationNo Current Residency Training University of Kentucky
1983.
State University of New York at Buffalo
1989
Associate dean for clinical To allow emergency medicine more input into medical school structure; to educate emergency affairs, faculty council medicinephysicians for state. Chair of surgery knew Chair negotiated departmental status prior to accepting position. and trusted chair of emergency medicine
programs should teach literature interpretation and research techniques as part of the curriculum in emergency medicine. Not only will this ensure that graduates of emergency m e d i c i n e r e s i d e n c y t r a i n i n g programs will be able to critically evaluate the medical literature, but it will als0 teach them .to design productive clinical and basic science research projects. Teaching emergency medicine research methodology is an investment in the future and is also the means to establish our own academic history and 'traditions, comparable to those already in place in other specialties. Able to draw on the collective research efforts of the past, the next generation of emergency physicians will be in a better position to make a stronger argument for a u t o n o m o u s departmental status. Spending time on research might 20:6:June1991
well require that a fellowship year be added to current emergency medicine residencies. The addition of an optional fellowship year for residents interested in teaching or research will allow t i m e for these f u t u r e emergency medicine educators to learn and practice these skills. Junior faculty just out of training must be provided with an environment and mentoring by senior faculty members that will allow them to become productive researchers on their own. Young faculty need protected time to prevent clinical and administrative duties from interfering with research. Optimally, this group should have 30% to 40% of their time available for research and career development (assuming a 55- to 60-hour work week) in order to make significant contributions and compete for funding. ~ Another strategy is to expand the Annals of Emergency Medicine
range of clinical studies conducted in the ED. The ED is an ideal location to apply and test the range of new technologies available in academic medical centers in a rational and cost-effective manner. Research in the ED also offers considerable opportunity for cooperative studies between emergency medicine and other departments, as well as multicenter studies w i t h existing e m e r g e n c y medicine training programs. Moreover, these cooperative intra- and int e r d e p a r t m e n t a l studies are more likely to be rewarding to the participants, to the medical center, and to the further development of the academic d e p a r t m e n t of e m e r g e n c y medicine. Clinical epidemiology, decision making, innovative treatment protocols, and health services research are all viable ventures in the ED. Students, residents, and f a c u l t y can 664/123
AUTONOMOUS DEPARTMENTS Rusnak, Hamilton & Allison
learn from studies in both basic and clinical science conducted in the outpatient setting, and the information generated by such ED research can be shared with fellow clinicians, basic scientists within the academic medical centers, and emergency medicine program directors. Because start-up funding to support these faculty is often difficult to find, a "seed money" research fund should be part of the resources in each emergency medicine training program. Grant applications for these funds would be submitted to a program committee for peer review on the basis of originality, relevance, excellence of design, ability to carry out the project, and budget. Writing grants for these intramural funds is valuable experience for faculty or residents who plan a career in academic medicine. A final strategy is to form intradepartmental study groups, each of which would have a specific research focus and in which junior faculty would work with senior faculty to "bootstrap" themselves in a career area for research. These various research foci and 0 mentoring system are more likely to be productive than having each new faculty m e m b e r strike out alone into uncharted waters; this system would be similar to the study groups used by the National Institutes of Health.
WORK BETWEEN T H E EMERGENCY MEDICINE PROGRAM AND THE MEDICAL S C H O O L M a n y p r o g r a m s (Table) h a v e achieved autonomous academic status through the use of leverage, such as the future department chair's negotiation of autonomous departmental status prior to accepting a departmental chairmanship or at least development of a legitimate blueprint for autonomous departmental recognition before accepting a job offer. Though a useful method, emergency medicine programs can no longer depend on such f o r t u i t o u s c i r c u m stances to achieve autonomous departmental status w i t h i n medical schools. Therefore, planning for departmental status necessarily entails crucial contacts with key figures within the academic medical center. These figures include the dean of the medical school, the chairs of various departments and committees, and 124/685
other individuals. This section focuses on ways to work with these important individuals.
The Dean The dean is usually the linchpin in the application process. In every case in which an application (by whatever process) has succeeded, the dean has played a critical role. In most medical schools, the dean has the power to initiate the establishment of a new department. The dean is also in a position to influence department chairs not favorably disposed to the application. Obviously, a great deal depends on the dean's open-mindedness regarding emergency medicine. After compiling information {perhaps drawn from a few years' worth of annual department reports) on the e m e r g e n c y medicine faculty's research, teaching, and service, the emergency medicine program director or a designee should meet with the dean to indicate the program's desire to become an autonomous academic department. It is important for the emergency medicine representative to have a certain a m o u n t of state- or universityqevel status. At the initial meeting, the emergency medicine representative should describe the advantages of an a u t o n o m o u s d e p a r t m e n t of emergency medicine. First, new emergency medicine departments are seldom a financial drain within an academic medical center; they usually generate m o r e r e v e n u e s than expenses because the impact of emergency medicine services and their financial rewards are considerable and likely to increase. Second, emergency medicine serves as one of the most visible links between the academic medical center and the surrounding c o m m u n i t y and generates new patients for the teaching population. Third, the emergency department will continue to be a training resource for the entire academic medical center, and other departments will not be excluded from training opportunities; consequently, other departments will not lose through emergency medicine's gain. Fourth, the new emergency medicine department chair shares the dean's commitment to medical school education, the protection of the curriculum, and the development of graduate medical education programs. Fifth, the emergency medicine deAnnals of Emergency Medicine
partment's efforts to develop the research base in emergency medicine represent a potential source of extramural funding. The precise strategy taken with the dean will vary and will depend on the heterogeneity of d e p a r t m e n t s w i t h i n the m e d i c a l school and on the type of medical school (public, private, religious). Once the dean is assured that the goals of the new emergency medicine chair are compatible with institutional goals, the advantages of an autonomous department of emergency medicine should be reviewed. These advantages vary from one institution to another (Table) and include the dev e l o p m e n t of i m p o r t a n t links between the university hospital and prehospital service; more effective recruitment of academic board-certified emergency physicians; better education for medical students and residents during their ED rotations; an improved ability to recruit superior students into emergency medicine residency training programs; and, importantly, better clinical care, which will reflect well on the institution and result in increased admissions and referrals. Finally, it should be emphasized that conferring departmental status represents a strengthening of the academic unit and its interaction with and c o m m i t m e n t to the m e d i c a l school; this mutual commitment is more likely to foster a productive relationship. Without such a commitment by the dean, the goals and objectives of an emergency medicine training program might be focused outside the dean's office; this change will inevitably weaken i m p o r t a n t bonds between ED faculty and the medical school as emergency medicine would experience inequality in the distribution of limited medical school resources. O t h e r m a t t e r s s h o u l d also be brought to the dean's attention. Information could be offered on the board certification process administered through the American Board of Medical Specialties and on the established postgraduate training programs at other US medical schools. It should be noted that emergency medicine has its own unique research, knowledge, and clinical service bases, and that autonomous department status will enhance its ability to teach this body of knowledge throughout the academfc medical center. The dean is 20:6 June 1991
AUTONOMOUS DEPARTMENTS Rusnak, Hamilton & Allison
usually well aware of the need to baL ance patient care and teaching and that the public's demand for expeditious and appropriate t r e a t m e n t leaves little room for misdiagnosis or therapeutic misadventure. It should be e m p h a s i z e d that in the EDs, where p a t i e n t care is m o n i t o r e d around the clock by emergency medicine faculty, both patient care and teaching are enhanced. O t h e r a r g u m e n t s could be advanced as appropriate to local circumstances. It could be argued that as a primary care specialty, emergency medicine plays a role in reestablishing the balance between primary care physicians and the many varieties of subspecialists trained in other areas. In approving autonomous department status for emergency medicine, the dean would begin addressing the current problem of overtraining subspecialists at the expense of primary care physicians and provide recognition of the educational and service components of our specialty. In most instances, emergency medicine has a service hours to faculty ratio that exceeds that of other departments. If the relationship with the dean is established and maintained in a mutually respectful manner, with each side conscious of the other side's concerns, this crucial contact will work to the advantage of the program seeking a u t o n o m o u s departmental status.
Department and Committee Chairs In most instances, the emergency medicine program will need other allies in addition to the dean. Most deans will not risk their own positions to champion emergency medicine's application if there is strong opposition from the chiefs of powerful Services. In some situations, the chief of surgery or internal medicine advanced the emergency medicine position to the dean (Table). It is therefore necessary for the emergency medicine representative to meet with each departmental chair to elicit support or uncover opposition or concerns so that these can be addressed. In addition, each program must assess its own unique interdepartmental relationships and decide on the departments most likely to provide the n e c e s s a r y s u p p o r t within the dean's office at the current time and in the future. 20:6:June1991
It is also necessary for the emergency medicine representative and faculty to join and perform well on key medical school committees, such as the admissions, promotions, and curriculum committees. By serving on these c o m m i t t e e s , e m e r g e n c y medicine faculty will have the opportunity (over time) to meet and problem solve with other medical school faculty members and chiefs and begin to develop the trusting relationships required during negotiations for autonomous department status. The curriculum committee is especially important. With e m e r g e n c y medicine representation on this committee, courses deficient in emergency medicine content can be identified, and topics especially relevant to emergency medicine can be introduced into the curriculum. Deficiencies will be rendered plain by comparing the current curriculum with a core content for undergraduate medical education in emergency medicine. The emergency medicine faculty can integrate emergency medicine topics into the curriculum by discussing new course content with various course directors, who then may be willing to share curriculum time for joint clinical teaching responsibility, if approved by the academic policy committee or a similar body. This may be promising because the move to emphasize training in primary care at the level of graduate medical education may trickle down to the undergraduate level.
Miscellaneous Support Other strategies to widen the base of support for the emergency medicine program's application include obtaining endorsement from private practitioners of emergency medicine in the community, the medical director of an institutional faculty practice plan (who understands the need for careful appropriate o u t p a t i e n t evaluation and treatment), the chief of staff at a community hospital that could serve as a training or research site for the university, or from the university hospital director because of emergency medicine's large service c o m p o n e n t . Such individuals can lend political support as well. T h e i m p o r t a n c e of e m e r g e n c y medicine could be stressed to legislators, who might question the medical school administration regarding the benefits of emergency medicine to Annals of Emergency Medicine
academic medical centers during the usual a d m i n i s t r a t i v e f u n d i n g requests to state legislatures. Last, an innovative approach might be to secure funding for an endowed chair in emergency medicine that would be granted to the academic medical center pending approval of autonomous department status.
PROJECTING AN EXPANDED ROLE FOR AN AUTONOMOUS DEPARTMENT In preparing for the process leading to the successful creation of a new department, the program director must develop and maintain an expanded view of the constituencies that may be served by the new department. Each potential constituency is analyzed carefully in terms of relationships, linkages, and politics under the categorical umbrella of research, teaching, and service. Though each setting has its own unique elements, the following groups are typical of the academic medical center: medical students, residents, fellows; faculty in emergency medicine and other specialties; departmental chairs in other specialties; medical school c o m m i t t e e m e m b e r s ; the dean, associate deans, and staff; vicepresident for health affairs; ED staff; the prehospital care system; other ED groups in the region; hospital administration; county medical societies; regional emergency medicine organizations; state organizations related to emergency medicine, emergency medical services, or health care; and national and international societies and organizations. By maintaining this broad perspective, the program director can search for advantages valued by the academic medical center that emergency medicine can bring to the institution. It is the accumulation of these valued advantages over time that becomes the central force in moving toward an autonomous academic department. Having these advantages also allows the department to fulfill its promise once the goal is reached.
SUMMARY In general, those departments of emergency medicine that currently enjoy autonomous department status w i t h i n academic medical centers have achieved their status largely through unplanned events, such as the ED director's administration of a 686/125
AUTONOMOUS DEPARTMENTS Rusnak, Hamilton & Allison
d i s t r e s s e d ED, t h e p r o v i s i o n of facu l t y to supervise p a t i e n t care in the ED, or the securing of a large Nat i o n a l I n s t i t u t e s of H e a l t h grant. In some cases, their status is the result of t h e e f f o r t s of s i n g l e - m i n d e d leaders in e m e r g e n c y m e d i c i n e w h o w a n t to m a n a g e t h e i r t r a i n i n g prog r a m s as do i n d e p e n d e n t d e p a r t m e n t s w i t h i n m e d i c a l schools. In the future, e m e r g e n c y m e d i c i n e
training programs must develop a m o r e deliberate approach to attaining autonomous departmental status. O n l y through such deliberate action will our specialty be assured of cont i n u e d growth in US m e d i c a l schools as we m o v e into the 21st century.
The authors thank Colleen Conniff for her assistance and forebearance, and the
Association of Academic Chairs of Emergency Medicine for their helpful comments, encouragement, and support during the preparation of this paper.
REFERENCES 1. Jones J, Dougherty J, Cannon L, et ah Teaching research in the emergency medicine residency curriculum. Ann Emerg Med 1987;16:347-353. 2. Sanders A: The development of researchers in emergency medicine: In emergency medicine. Academic Emergency Medicine 1990;2:1-2.
See related editorial, p 698.
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Annals of Emergency Medicine
20:6 June 1991
Autonomous Departments of Emergency Medicine in Contemporary Academic Medical Centers There are currently 20 autonomous departments of emergency medicine in United States medical schools. EDs seeking autonomous status should institute a faculty development program to channel faculty energy into worthwhile research projects; establish protected time for clinical faculty to increase research productivity; develop expertise to compete for extramural funding; initiate an intramural research program so that faculty can learn the basics of grantsmanship; teach health care issues in ambulatory medicine; become involved in interdisciplinary teaching programs and curriculum development; maintain the present faculty c o m m i t m e n t to 24hour attending coverage; and develop university-based programs that originate from the ED. Program directors should establish liaisons with the medical school dean to acquaint him with the advantages of an autonomous department of emergency medicine; attempt to assess other relationships within the medical school to determine support for emergency medicine and to uncover and address opposition to autonomous departmental status; attempt to serve on medical school committees to meet other faculty, solve problems with them and develop trusting relationships; and develop broad-based support for autonomous departmental status both within and outside of the university. By devising and following a deliberate approach to attaining departmental status, emergency medicine will be assured of continued growth in the important decade ahead. [Rusnak RA, Hamilton GC, Allison EJ Jr: Autonomous departments of emergency medicine in contemporary academic medical centers. Ann Emerg Med June 1991;20:680-687.]
INTRODUCTION With the September 1989 vote by the American Board of Medical Specialties to approve primary board certification for emergency medicine, our specialty has been granted de facto recognition of its important place in contemporary American medicine. Hence now is an appropriate time to increase our efforts to win wider acceptance for our specialty within academic medical centers. Since its inception in 1968, the specialty of emergency medicine has matured along several lines. First, emergency medicine has greatly improved the quality of patient care in emergency departments while simultaneously treating a steadily growing patient population. Second, residency training programs have been developed. Third, a superlative specialty examination process has been created. Fourth, a research base unique to our discipline has developed and is expanding. The next important task is to elevate our specialty's standing through a concentrated effort to establish autonomous departments of emergency medicine within our medical schools. Currently, there are 20 autonomous academic departments of emergency medicine in US medical schools. The tal~le lists these departments and indicates the factors that were critical in their establishment. Many were created in the early 1970s, in response to such circumstances as the approval of an emergency medicine residency training program, the salvaging of an ED experiencing clinical service problems, or as a pre-employment agreement with an individual being recruited for the faculty. In the last decade, however, emergency medicine has realized that a more systematic approach is necessary to secure its
20:6 June 1991
Annals of Emergency Medicine
Robert A Rusnak, MD* Minneapolis, Minnesota Glenn C Hamilton, MD~ Dayton, Ohio E Jackson Allison Jr, MD, FACEP* Greenville, North Carolina From the Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota;* the Department of Emergency Medicine, Wright State University, Dayton, Ohio;~ and the Department of Emergency Medicine, East Carolina University, Greenville, North Carolina.* Received for publication July 3, 1990. Revision received December 3, 1990. Accepted for publication December 28, 1990. This paper was written under the auspices of the Association of Academic Chairs of Emergency Medicine and the Society for Academic Emergency Medicine. Address for reprints: Robert A Rusnak, MD, Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, Minnesota 55415.
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AUTONOMOUS DEPARTMENTS Rusnak, Hamilton & Allison
place within academe. Before embarking on the long and arduous journey toward autonomous departmental status, the emergency physician who will be driving the process must understand the values of the institution in which the emergency medicine program finds itself. These values usually revolve around the specific "weighting" or credits given for research, service, education, administration, financial contribution, and longevity by the institution. The institution will grant the request for autonomous departmental status only if the capabilities and status of e m e r g e n c y medicine are c o n s i s t e n t w i t h the i n s t i t u t i o n ' s values and will further its goals. If this is not the case, the process may be doomed before it starts. Although it is possible to change the value system of an institution, this task is n o t o r i o u s l y difficult. Most basic changes in a c a d e m i c medical centers have occurred due to the influence of powerful external (eg, the state or federal government) or internal (eg, the medical school dean or the vice-president for health affairs) forces. It is doubtful that an emergency medicine residency training program director acting alone can effect this change. If the institution's values are incompatible with autono ~ mous departmental status for emergency medicine, knowing this at the outset can allow one to avoid frustration and adjust one's ambitions. Under these circumstances, the emergency medicine program director's choices are to scale down the objective (eg, to divisional status or to simple survival of the program) or to leave the organization. To d i s c o v e r the i n s t i t u t i o n ' s values, one should hold discussions with at least three key people: the dean, the chairperson or a cooperative member of the promotions and tenure c o m m i t t e e , and a f a c u l t y member who is successful in the system, yet is allied to emergency medicine's ambitions. Ideally, one or more of the three will later assist in mentoring emergency medicine through the process. The questions to be asked are simple. What does the institution value? How do its values translate into the criteria for promotion and tenure? What actions can the emergency medicine program take that will be consistent with the institution's values? Are there ex120/681
plicit and implicit values within the medical school, and what are their differences? (This last question is best reserved for the individual(s] willing to act as a mentor; asking the wrong parties risks backlash and misinformation.) Once this system is well understood and the values of emergency medicine are seen to coincide w i t h t h o s e of the m e d i c a l school, one can undertake a course toward autonomy, confident of the emergency medicine request's chances for success. In addition to assessing the value s y s t e m of the m e d i c a l school in which the emergency medicine training program wishes to establish an a u t o n o m o u s d e p a r t m e n t of emergency medicine, it is also important to bring to the fore the benefits to be gained from a successful effort. In this way, the emergency medicine training program can weigh the costs and benefits of the considerable effort to be expended during this process to help decide whether an autono m o u s d e p a r t m e n t of e m e r g e n c y medicine is desirable. The p r i m a r y v a l u e of m e d i c a l school affiliation as an autonomous d e p a r t m e n t is influence over the forces that shape the destiny and direction of an emergency medicine training program within the medical school hierarchy. This power resides in three areas: the power of space allocation within the institution; the power to r e c o m m e n d faculty and staff appointments~ and influence over financial resource allocation. As a departmental chairman, an individual will also have the opportunity to appoint faculty or become a member of i n t r a d e p a r t m e n t a l c o m m i t t e e s within the university. These committees should include the following: the C o m m i t t e e of Chairmen; the Dean's Special Committee (also referred to as the Dean's Advisory Committee); the Committee of Clinical Chairmen (usually formed outside the Dean's control in w h i c h m e m b e r s discuss the direction of their own clinical and collective services); and the Faculty Practice Committee. After careful consideration of the benefits to be gained and the sacrifices necessary to achieve autonomous d e p a r t m e n t a l status, emergency medicine training programs will be in a position to decide on an approach for achieving that status. In Annals of Emergency Medicine
this way, when negotiations begin, emergency medicine programs will know what they are willing to sacrifice to achieve autonomous departmental status. In this article, it is assumed that academic emergency medicine departments have a legitimate place within medical schools. Emergency m e d i c i n e r e s i d e n c y t r a i n i n g programs that do not yet enjoy autonomous department status are offered suggestions for attaining such status. Two basic areas of work are discussed: that done within the EM residency training program and that done between the program and the medical school in which it is seeking autonomous department status. The former includes a program for faculty development and programs intended to improve the productivity and prom o t a b i l i t y of c u r r e n t e m e r g e n c y medicine faculty, mindful of an institution's value system for research, teaching, and service. The latter includes the nurturing of a mutually respectful relationship with the medical school dean, discussions with department and committee chairs, and greater participation in medical school instructional programs. This article proposes a strategy for the important decade to come, a decade in which we anticipate that emergency medicine will succeed in its efforts to be fully recognized within each medical school in the United States.
WORK WITHIN THE EMERGENCY MEDICINE RESIDENCY TRAINING PROGRAM Traditionally, the academic promotion of an individual is based on research, teaching, and service (eg, patient care or administration). It follows that improving the promotion credentials of individual faculty will improve the credentials of the program seeking a u t o n o m o u s department status. This section focuses on improving the prospective department's promotability to demonstrate compliance with the rigorous standards expected of an autonomous department. As mentioned earlier, understanding the promotion pathway is an important means of understanding the institution's value system.
Faculty Development Research and publication are two very important academic activities. 20:6 June 1991
AUTONOMOUS DEPARTMENTS Rusnak, Hamilton & Allison
The unique skills required for success in these areas, however, often require coaching. A program will benefit greatly by appointing an experienced research director (MD or PhD) who can serve as an advisor for less experienced faculty and can generally channel faculty energy into promising areas of investigation. If, as we hope, our specialty society develops liaisons with the organized research community in the United States, and assuming that the network within academic emergency medicine continues to grow (eg, the Society for Academic Emergency Medicine), the research director would serve as the program's chief contact person for keeping abreast of new developments in the field and would encourage less experienced faculty to pursue fundable research projects. This individual will serve best if given the opportunity to lead by example. A faculty development plan should allow time for teaching the skills needed to write research papers and grant applications or the emergency medicine program should establish access to this expertise. The program should also strive to engage in joint research projects that involve experienced grant writers within or outside the institution. "Riding the coattails" of an experienced investigator is an important traditional, apprentice method of learning research and grantsmanship.
Research At present, the foremost promotion criteria at research universities is original, credible research and p e e r - r e v i e w e d p u b l i c a t i o n . Such work is essential for both individual faculty and the program as a whole. Due to its obvious relationship to research and publication, the procurement of extramural funding is also important; an established history in this area adds significant support to the emergency medicine program's request for autonomous departmental status. For clinical faculty within medical schools, there has been a shift in the criteria for m e d i c a l school advancement. As service demands have increased, retention of skilled h e a l t h care providers and teachers has become critical. Some i n s t i t u t i o n s (eg, Harvard Medical School) have therefore increased the time allowed for clinical faculty to demonstrate research productivity 20:6:June1991
from seven to nine years. This trend works to the advantage of a specialty with high clinical service demands (eg, emergency medicine) by allowing more time for research and academic development and thereby increasing the probability of advancement.
Teaching Programs applying for autonomous departmental status must also establish and document a history of excellent teaching of medical students and residents in and outside of the emergency departments. EDs that are part of academic medical centers have patient populations that provide an ideal setting for hands-on teaching in the evaluative, procedural, and diagnostic skills needed by all physicians. Outside academic medical centers, community hospital EDs have caseloads that are often large and are comprised of diverse patient populations; these settings are also well suited to teaching and research3 Many c o m m u n i t y hospitals associated with academic medical centers are i m p o r t a n t sites of r e s i d e n c y training. This need will only increase as academic medical center inpatient populations decrease and these centers look to other places for the patients required to maintain their undergraduate and graduate teaching programs. The major teaching effort should be directed toward medical students. At a minimum, freshmen and sophomores need instruction in basic life support. Juniors and seniors benefit from instruction in advanced cardiac life support, and rotations in the ED often give students their first opportunity to perform an evaluation on patients with unselected complaints. The opportunity for such basic procedures as IV access and simple minor wound care is unsurpassed in the ED. W h e n the c u r r i c u l u m is thoughtfully designed and enthusiastically delivered, these students often rate their ED rotation as their best training experience in medical school. For both graduate and undergraduate students of medicine, the ED is an ideal place to teach subjects such as acute care medicine, trauma resuscitation, minor surgery, pediatrics, obstetrics and gynecology, ambulatory care, and the basics of radiology and forensic medicine. The ED is also a natural setting for instruction Annals of Emergency Medicine
in the social issues in medicine, such as care of the poor and indigent, access to treatment, appropriateness of treatment (including cost effectiveness}, rationing and resource allocation, and biomedical ethics. The ED also provides opportunities for students to learn in areas closely related to medicine, such as epidemiology, public health, and health education. Emergency medicine faculty should also take an active role in interdisciplinary teaching and curriculum development. Emergency medicine faculty can teach or be involved in courses that provide clinical correlations for diseases taught in the basic sciences, courses in clinical problem-solving, introductory courses in clinical laboratory medicine, and p h y s i c a l e x a m i n a t i o n courses.
Emergency medicine program directors should tally the data on the total number of medical students, interns, and residents taught each year. Programs should also tally the data on other educational activities such as m e d i c a l s c h o o l c o u r s e s and courses in advanced trauma and cardiac life support. Also included here are postgraduate continuing medical education programs presented during hospital conferences and presentations at state and national meetings. Evaluation is integral to this process; faculty with teaching excellence s h o u l d be recognized, especially those with national or international reputations.
Service The third component in a successful strategy for a u t o n o m o u s academic department status is a demonstrable commitment to excellence in serving patients in the community outside the academic medical center. Through their commitment to provide 24-hour ED coverage, thus ensuring constant access to high-quality care, emergency medicine faculty already fulfill a significant service function. In addition to their continuous presence in the ED, emergency medicine faculty also involve other specialists in patient care, thereby integrating themselves and their program into the fabric of the academic medical center. There are numerous other ways for emergency medicine faculty to contribute to their program's commitment to service. They can serve as 682/121
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TABLE. Autonomous departments of emergency nledicine
Medical School
Date of Department Formation 1971
Dean
University of Louisville
1971
Dean
University of MissouriKansas City School of Medicine Wright State University
1972
Dean, medical school administrative structure
1980
Dean
East Carolina University
1980
Dean
Charles Drew Medical School
1981
Chair of surgery
Loma Linda School of Medicine George Washington University Medical College of Pennsylvania
1982
Dean, hospital administrator Dean, faculty senate
1984
Chair of surgery lobbied support from other departmental chairs
University of Cincinnati
1984
Dean
Albany Medical School
1986
Georgetown University
1986
Dean; medical director of institutional faculty practice plan Chair of surgery knew and trusted chair of emergency medicine
Northwestern Ohio Universities College of Medicine
1986
Emergency physicians in multiple local teaching hospital; academic chairs supportive of emergency medicine
medical directors of ambulance services, helicopter services, emergency medical services training programs, city fire and police departments, and statewide poison control networks; they can sit on disaster p l a n n i n g boards and the boards of state and national emergency medicine service councils; they can become politically active in such areas as handgun control, mandatory seat belt use, and helmet legislation. Emergency medicine program directors should plan the involvement of emergency medicine faculty in these and other areas and incorporate this faculty participation as focus areas for ongoing de122/683
-
1990
Significant Support Factors Considered Important During Deliberations to Form Within Medical School New Autonomous Department
University ot Southern California
1984
-
Chief negotiated department status prior to accepting position; teaching (medical students); emergency medical services activity; separate budget; research credentials of faculty; clinical reputation; chair principal investigator of Health Education and Welfare grant for training emergency medicine residents and quality assurance. Chair reorganizeddistressed department, procured emergency medical services grant money, negotiated departmentstatus prior to accepting position. Emergency medicine a separate hospital departmentand when medical school was formed in 1970, the medical school adopted hospital department structure as medical school department structure. Prearrangementwith dean based on developmentof residency program, student education, and level of scholarly activity. Medical school intent to bolster teaching in family practice and primary care; chair negotiated departmental status prior to accepting position. Clinical service (70% hospital admissions through ED); establishment ol emergency medicine residency; Hearth, Education and Wetfare grant procured by emergencymedicine for emergency medical services; previous difficulty retaining faculty Clinical service issues and equitable agreementsbetween surgery, medicine, and pediatrics. Protecting hospital against liability: clinical service; residency training program, medical student teaching; continuing medical education courses by emergency medicine. High-quality clinical service; large emergency medicine residency training program, emergency medicine part of medical school curriculum; teachingl publications; presence of faculty in national organizations;division of department o1 surgery for 12 years before achieving autonomous status. Chair negotiated departmentalstatus prior to accepting position (freestanding division of Dean's office before achieving autonomous status); research; publications; extramural funding; clinical skills of faculty; commitment to teaching; emergencymedicine residency training. Chief negotiated departmentalstatus prior to accepting position. New department would solve clinical service problems, improve patient care, enhance revenue, improve resident, faculty recruiting. Physical separation of ED from internal medicine; no negative effect on internal medicine; residency training programs and board certification examinationsseparate from internal medicine; improvement in faculty recruitment; teaching achievements; potential to enhance national reputation in emergencymedicine; community involvement. Presence of two weft-establishedemergencymedicine residency programs; medical student teaching; faculty involved in medical school instructional programs.
p a r t m e n t a l research and development of position papers, review articles, and educational p r o g r a m s to ensure academic medical center recognition of efforts in these areas. Also, it is advantageous for emergency medicine programs to develop university-based programs that originate from the ED. Steps to enhance the visibility and status of the university {and emergency medicine within the university) include assuming the medical directorship of a university hyperbaric facility, directing a university or statewide helicopter a m b u l a n c e service, administering a rural.mediAnnals of Emergency Medicine
cine outreach program, and developing a statewide program to improve trauma care.
Growth of the Research Base in Emergency Medicine Establishing faculty development programs in emergency medicine residency training programs and enhancing the promotion credentials of faculty will heighten the status of individual residency training programs in emergency medicine and will also contribute to the growth of the specialty. To foster the growth of a specialty-wide research base in emergency medicine, residency training 20:6 June 1991
AUTONOMOUS DEPARTMENTS Rusnak, Hamilton & Allison
TABLE. A u t o n o m o u s d e p a r t m e n t s of e m e r g e n c y m e d i c i n e - 1990 (continued)
Medical School
Date of Department SignificantSupport Factors Considered Important During Deliberations to Form Formation Within Medical School New Autonomous Department
Medical College of Pennsylvania AJiegheny Campus Bowman Gray School of Medicine Ohio State University
1988
State University of New York-Stonybrook
1990
Texas Tech University
1990
University of North Carolina-ChapelHill
1990
Wayne State University
1990
-
Association of Allegheny General Hospital with Medical College of Pennsylvania;because emergency medicine was already an autonomous departmentat the Philadelphia campus, Allegheny followed same course; functionally a division of departmentof surgery Medical school reorganizationof department of surgery.
1989
Chair of surgery
1990
Dean, former chairs of surgery, preventive medicine, internal medicine Dean
Dean, hospital administration, department of surgery Dean, medical school and hospital administration Dean, chair of surgery
Emergency medicine curriculum in medical school (1st year and elective 4th year); excellent clinical service; research base in emergency medicine; establishment of an autonomous department would facilitate Residency Review Committee approval for emergency medicine residency training program, initially an independentprogram administered by dean. Medical student teaching; patient care in ED; emergencymedical services leadership; initiation of a research base in emergencymedicine; establishment of an autonomous department would facilitate Residency Review Committee approval for emergency medicine residency training program, initially an independentprogram administered by dean. Cfinical service; physical separation from other departments of medical school (based in Lubbock); faculty retention; developmentof residency. Attending coverage in ED for problem solving and quality assurance. Funding from hospital administration and medical school; developmentof emergency medicine residency; improved administrative organization of ED. Incoming chief asked dean to develop criteria for formation of a new departmentthat developed along with those suggested by dean, including high-quality clinical service; development of excellent faculty; well-trained residents and students; scholarly activity reflected by grants and publications.
Medical School AffiliationNo Current Residency Training University of Kentucky
1983.
State University of New York at Buffalo
1989
Associate dean for clinical To allow emergency medicine more input into medical school structure; to educate emergency affairs, faculty council medicinephysicians for state. Chair of surgery knew Chair negotiated departmental status prior to accepting position. and trusted chair of emergency medicine
programs should teach literature interpretation and research techniques as part of the curriculum in emergency medicine. Not only will this ensure that graduates of emergency m e d i c i n e r e s i d e n c y t r a i n i n g programs will be able to critically evaluate the medical literature, but it will als0 teach them .to design productive clinical and basic science research projects. Teaching emergency medicine research methodology is an investment in the future and is also the means to establish our own academic history and 'traditions, comparable to those already in place in other specialties. Able to draw on the collective research efforts of the past, the next generation of emergency physicians will be in a better position to make a stronger argument for a u t o n o m o u s departmental status. Spending time on research might 20:6:June1991
well require that a fellowship year be added to current emergency medicine residencies. The addition of an optional fellowship year for residents interested in teaching or research will allow t i m e for these f u t u r e emergency medicine educators to learn and practice these skills. Junior faculty just out of training must be provided with an environment and mentoring by senior faculty members that will allow them to become productive researchers on their own. Young faculty need protected time to prevent clinical and administrative duties from interfering with research. Optimally, this group should have 30% to 40% of their time available for research and career development (assuming a 55- to 60-hour work week) in order to make significant contributions and compete for funding. ~ Another strategy is to expand the Annals of Emergency Medicine
range of clinical studies conducted in the ED. The ED is an ideal location to apply and test the range of new technologies available in academic medical centers in a rational and cost-effective manner. Research in the ED also offers considerable opportunity for cooperative studies between emergency medicine and other departments, as well as multicenter studies w i t h existing e m e r g e n c y medicine training programs. Moreover, these cooperative intra- and int e r d e p a r t m e n t a l studies are more likely to be rewarding to the participants, to the medical center, and to the further development of the academic d e p a r t m e n t of e m e r g e n c y medicine. Clinical epidemiology, decision making, innovative treatment protocols, and health services research are all viable ventures in the ED. Students, residents, and f a c u l t y can 664/123
AUTONOMOUS DEPARTMENTS Rusnak, Hamilton & Allison
learn from studies in both basic and clinical science conducted in the outpatient setting, and the information generated by such ED research can be shared with fellow clinicians, basic scientists within the academic medical centers, and emergency medicine program directors. Because start-up funding to support these faculty is often difficult to find, a "seed money" research fund should be part of the resources in each emergency medicine training program. Grant applications for these funds would be submitted to a program committee for peer review on the basis of originality, relevance, excellence of design, ability to carry out the project, and budget. Writing grants for these intramural funds is valuable experience for faculty or residents who plan a career in academic medicine. A final strategy is to form intradepartmental study groups, each of which would have a specific research focus and in which junior faculty would work with senior faculty to "bootstrap" themselves in a career area for research. These various research foci and 0 mentoring system are more likely to be productive than having each new faculty m e m b e r strike out alone into uncharted waters; this system would be similar to the study groups used by the National Institutes of Health.
WORK BETWEEN T H E EMERGENCY MEDICINE PROGRAM AND THE MEDICAL S C H O O L M a n y p r o g r a m s (Table) h a v e achieved autonomous academic status through the use of leverage, such as the future department chair's negotiation of autonomous departmental status prior to accepting a departmental chairmanship or at least development of a legitimate blueprint for autonomous departmental recognition before accepting a job offer. Though a useful method, emergency medicine programs can no longer depend on such f o r t u i t o u s c i r c u m stances to achieve autonomous departmental status w i t h i n medical schools. Therefore, planning for departmental status necessarily entails crucial contacts with key figures within the academic medical center. These figures include the dean of the medical school, the chairs of various departments and committees, and 124/685
other individuals. This section focuses on ways to work with these important individuals.
The Dean The dean is usually the linchpin in the application process. In every case in which an application (by whatever process) has succeeded, the dean has played a critical role. In most medical schools, the dean has the power to initiate the establishment of a new department. The dean is also in a position to influence department chairs not favorably disposed to the application. Obviously, a great deal depends on the dean's open-mindedness regarding emergency medicine. After compiling information {perhaps drawn from a few years' worth of annual department reports) on the e m e r g e n c y medicine faculty's research, teaching, and service, the emergency medicine program director or a designee should meet with the dean to indicate the program's desire to become an autonomous academic department. It is important for the emergency medicine representative to have a certain a m o u n t of state- or universityqevel status. At the initial meeting, the emergency medicine representative should describe the advantages of an a u t o n o m o u s d e p a r t m e n t of emergency medicine. First, new emergency medicine departments are seldom a financial drain within an academic medical center; they usually generate m o r e r e v e n u e s than expenses because the impact of emergency medicine services and their financial rewards are considerable and likely to increase. Second, emergency medicine serves as one of the most visible links between the academic medical center and the surrounding c o m m u n i t y and generates new patients for the teaching population. Third, the emergency department will continue to be a training resource for the entire academic medical center, and other departments will not be excluded from training opportunities; consequently, other departments will not lose through emergency medicine's gain. Fourth, the new emergency medicine department chair shares the dean's commitment to medical school education, the protection of the curriculum, and the development of graduate medical education programs. Fifth, the emergency medicine deAnnals of Emergency Medicine
partment's efforts to develop the research base in emergency medicine represent a potential source of extramural funding. The precise strategy taken with the dean will vary and will depend on the heterogeneity of d e p a r t m e n t s w i t h i n the m e d i c a l school and on the type of medical school (public, private, religious). Once the dean is assured that the goals of the new emergency medicine chair are compatible with institutional goals, the advantages of an autonomous department of emergency medicine should be reviewed. These advantages vary from one institution to another (Table) and include the dev e l o p m e n t of i m p o r t a n t links between the university hospital and prehospital service; more effective recruitment of academic board-certified emergency physicians; better education for medical students and residents during their ED rotations; an improved ability to recruit superior students into emergency medicine residency training programs; and, importantly, better clinical care, which will reflect well on the institution and result in increased admissions and referrals. Finally, it should be emphasized that conferring departmental status represents a strengthening of the academic unit and its interaction with and c o m m i t m e n t to the m e d i c a l school; this mutual commitment is more likely to foster a productive relationship. Without such a commitment by the dean, the goals and objectives of an emergency medicine training program might be focused outside the dean's office; this change will inevitably weaken i m p o r t a n t bonds between ED faculty and the medical school as emergency medicine would experience inequality in the distribution of limited medical school resources. O t h e r m a t t e r s s h o u l d also be brought to the dean's attention. Information could be offered on the board certification process administered through the American Board of Medical Specialties and on the established postgraduate training programs at other US medical schools. It should be noted that emergency medicine has its own unique research, knowledge, and clinical service bases, and that autonomous department status will enhance its ability to teach this body of knowledge throughout the academfc medical center. The dean is 20:6 June 1991
AUTONOMOUS DEPARTMENTS Rusnak, Hamilton & Allison
usually well aware of the need to baL ance patient care and teaching and that the public's demand for expeditious and appropriate t r e a t m e n t leaves little room for misdiagnosis or therapeutic misadventure. It should be e m p h a s i z e d that in the EDs, where p a t i e n t care is m o n i t o r e d around the clock by emergency medicine faculty, both patient care and teaching are enhanced. O t h e r a r g u m e n t s could be advanced as appropriate to local circumstances. It could be argued that as a primary care specialty, emergency medicine plays a role in reestablishing the balance between primary care physicians and the many varieties of subspecialists trained in other areas. In approving autonomous department status for emergency medicine, the dean would begin addressing the current problem of overtraining subspecialists at the expense of primary care physicians and provide recognition of the educational and service components of our specialty. In most instances, emergency medicine has a service hours to faculty ratio that exceeds that of other departments. If the relationship with the dean is established and maintained in a mutually respectful manner, with each side conscious of the other side's concerns, this crucial contact will work to the advantage of the program seeking a u t o n o m o u s departmental status.
Department and Committee Chairs In most instances, the emergency medicine program will need other allies in addition to the dean. Most deans will not risk their own positions to champion emergency medicine's application if there is strong opposition from the chiefs of powerful Services. In some situations, the chief of surgery or internal medicine advanced the emergency medicine position to the dean (Table). It is therefore necessary for the emergency medicine representative to meet with each departmental chair to elicit support or uncover opposition or concerns so that these can be addressed. In addition, each program must assess its own unique interdepartmental relationships and decide on the departments most likely to provide the n e c e s s a r y s u p p o r t within the dean's office at the current time and in the future. 20:6:June1991
It is also necessary for the emergency medicine representative and faculty to join and perform well on key medical school committees, such as the admissions, promotions, and curriculum committees. By serving on these c o m m i t t e e s , e m e r g e n c y medicine faculty will have the opportunity (over time) to meet and problem solve with other medical school faculty members and chiefs and begin to develop the trusting relationships required during negotiations for autonomous department status. The curriculum committee is especially important. With e m e r g e n c y medicine representation on this committee, courses deficient in emergency medicine content can be identified, and topics especially relevant to emergency medicine can be introduced into the curriculum. Deficiencies will be rendered plain by comparing the current curriculum with a core content for undergraduate medical education in emergency medicine. The emergency medicine faculty can integrate emergency medicine topics into the curriculum by discussing new course content with various course directors, who then may be willing to share curriculum time for joint clinical teaching responsibility, if approved by the academic policy committee or a similar body. This may be promising because the move to emphasize training in primary care at the level of graduate medical education may trickle down to the undergraduate level.
Miscellaneous Support Other strategies to widen the base of support for the emergency medicine program's application include obtaining endorsement from private practitioners of emergency medicine in the community, the medical director of an institutional faculty practice plan (who understands the need for careful appropriate o u t p a t i e n t evaluation and treatment), the chief of staff at a community hospital that could serve as a training or research site for the university, or from the university hospital director because of emergency medicine's large service c o m p o n e n t . Such individuals can lend political support as well. T h e i m p o r t a n c e of e m e r g e n c y medicine could be stressed to legislators, who might question the medical school administration regarding the benefits of emergency medicine to Annals of Emergency Medicine
academic medical centers during the usual a d m i n i s t r a t i v e f u n d i n g requests to state legislatures. Last, an innovative approach might be to secure funding for an endowed chair in emergency medicine that would be granted to the academic medical center pending approval of autonomous department status.
PROJECTING AN EXPANDED ROLE FOR AN AUTONOMOUS DEPARTMENT In preparing for the process leading to the successful creation of a new department, the program director must develop and maintain an expanded view of the constituencies that may be served by the new department. Each potential constituency is analyzed carefully in terms of relationships, linkages, and politics under the categorical umbrella of research, teaching, and service. Though each setting has its own unique elements, the following groups are typical of the academic medical center: medical students, residents, fellows; faculty in emergency medicine and other specialties; departmental chairs in other specialties; medical school c o m m i t t e e m e m b e r s ; the dean, associate deans, and staff; vicepresident for health affairs; ED staff; the prehospital care system; other ED groups in the region; hospital administration; county medical societies; regional emergency medicine organizations; state organizations related to emergency medicine, emergency medical services, or health care; and national and international societies and organizations. By maintaining this broad perspective, the program director can search for advantages valued by the academic medical center that emergency medicine can bring to the institution. It is the accumulation of these valued advantages over time that becomes the central force in moving toward an autonomous academic department. Having these advantages also allows the department to fulfill its promise once the goal is reached.
SUMMARY In general, those departments of emergency medicine that currently enjoy autonomous department status w i t h i n academic medical centers have achieved their status largely through unplanned events, such as the ED director's administration of a 686/125
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d i s t r e s s e d ED, t h e p r o v i s i o n of facu l t y to supervise p a t i e n t care in the ED, or the securing of a large Nat i o n a l I n s t i t u t e s of H e a l t h grant. In some cases, their status is the result of t h e e f f o r t s of s i n g l e - m i n d e d leaders in e m e r g e n c y m e d i c i n e w h o w a n t to m a n a g e t h e i r t r a i n i n g prog r a m s as do i n d e p e n d e n t d e p a r t m e n t s w i t h i n m e d i c a l schools. In the future, e m e r g e n c y m e d i c i n e
training programs must develop a m o r e deliberate approach to attaining autonomous departmental status. O n l y through such deliberate action will our specialty be assured of cont i n u e d growth in US m e d i c a l schools as we m o v e into the 21st century.
The authors thank Colleen Conniff for her assistance and forebearance, and the
Association of Academic Chairs of Emergency Medicine for their helpful comments, encouragement, and support during the preparation of this paper.
REFERENCES 1. Jones J, Dougherty J, Cannon L, et ah Teaching research in the emergency medicine residency curriculum. Ann Emerg Med 1987;16:347-353. 2. Sanders A: The development of researchers in emergency medicine: In emergency medicine. Academic Emergency Medicine 1990;2:1-2.
See related editorial, p 698.
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