EDITORIALS Emergency Medicine Faculty Shortage The Medical School Perspective Academic emergency medicine has made great strides during the past decade. Research in emergency medicine has become more sophisticated, and emergency physicians are successfully competing for major grant support. Academic contributions in areas such as emergency medical services, trauma, environmental injuries, resuscitation, and toxicology have been well received by our colleagues in other specialties. As the number of emergency medicine programs increases, we realize that there is a shortage of well-qualified faculty in academic emergency medicine. The Residency Review Committee for Emergency Medicine reports that a shortage of well-qualified faculty is one of the major deficiencies in programs they review. There are several medical centers where the political and economic support to start academic divisions and residency training programs in emergency medicine has been developed, but a program cannot be started until a core of qualified faculty is recruited, l Even well-established programs have difficulty recruiting faculty who are well trained and able to compete in academics. Well-trained academicians have generally completed not only residency programs but also several years of fellowship training to acquire the skills necessary to teach and make scholarly contributions comparable to those of colleagues in other disciplines. Like all good problems, the etiology of the faculty shortage is multifactorial. We are a new specialty that grew out of a clinical need in our health-care system; we do not have the traditional lines of academic mentors and growth that are prevalent in other specialties. While other factors include residents' attitudes toward academics and faculty development, the problem begins in medical schools. It is difficult for medical students to view emergency medicine as an academic discipline if they are not exposed to it during their training. Emergency medicine is a full academic department in only 14 medical schools. Less than one half of US medical schools have residency training programs in emergency medicine: ~ Less than one third of schools require clinical time in emergency medicine. Therefore, most medical students are exposed to emergency medicine primarily as a clinical discipline; this was reflected in the annual survey of senior medical students conducted by the American Association of Medical Colleges. 3-s The Society for Academic Emergency Medicine recently reviewed these survey data from the past five years. The responses of students choosing emergency medicine as a career were compared with those of all senior students. Compared with 10% of all students, 35% of students going into emergency medicine responded that the most important factor in their choice of specialty was "challenging diagnostic problems." In contrast, 35% of all students compared with 16% of students going into emergency medicine stated that the most important factor in their choice of specialty was the "intellectual content of the specialty. ''3 19:7 July 1990
Several questions focused on research experience and plans. Thirty-nine percent of students going into emergency medicine participated in a research investigation compared with 47% of all graduating students in 1989. Twenty-one percent of students choosing emergency medicine in 1989 had authored a paper compared with 30% of all students. Research experience for students choosing emergency medicine was more common in 1989 than in 1985, when 30% of students were involved in a research project. In 1989, 12% of students entering emergency medicine said they planned a research fellowship after r e s i dency training compared with 6% in 1985. Although this represents an increase, it was still less than the 23% of all medical students in 1989 who said that their future plans included a research fellowship. Five percent of those going into emergency medicine in 1989 planned a research fellowship focusing on basic medical sciences. In 1985, none of the students planning a fellowship intended to focus on basic medical sciences. 3-s When students going into emergency medicine were asked about their career plans, 27% in 1989 and 19% in 1985 expressed a desire for a career in clinical science teaching and research compared with 29% of all medical students. Some students, however, may have unrealistic views of careers in academic emergency medicine. Although 27% wanted a career in academics, only 7% of students choosing emergency medicine said that they planned to be significantly involved in research involving at least 25% of their career time. In contrast, 15% of all students planned to be significantly involved in research.3-s Thus, students choosing emergency medicine enjoy the clinical aspects and diagnostic challenges. During the past five years, more students choosing emergency medicine expressed interest in academics. Many would like a career in academic emergency medicine but tend to be less interested in fellowship training and in being significantly involved with research than colleagues going into other specialties. It is important for students to understand that academic faculty must be truly involved in research and scholarly activities. As a specialty, we must be able to attract more students who are interested in emergency medicine research as a career. In a recent review of medical school honors graduates (AOA members) in 1982 and 1983 in nine of the top medical schools in the country, Golden found that emergency medicine was underweighted in the number of honors students choosing this specialty compared with other specialties. 6 This was somewhat surprising as our specialty is greatly oversubscribed and many of the residents selected are honors students. It is significant, however, that only two of these medical schools have residency training programs in emergency medicine, and none of the schools has an academic department or requires clerkships. During the next decade, it is essential that emergency medi-
Annals of Emergency Medicine
826/143
EDITORIALS
cine be established academically in all medical schools throughout the country. This is particularly important in the top ten to 20 medical schools, which will produce a significant percentage of clinical scientists and academic scholars. Faculty who teach emergency medicine to medical students, regardless of whether there is a residency training program, must be active researchers and scholars as well as clinicians. It is important for medical students who want a career in academics to view emergency medicine as a thriving academic discipline. Like all complex problems, there are no "quick-fix" solutions. In fact, the faculty shortage itself makes it difficult for young faculty to devote time and energy to acquiring the research and academic skills that are necessary to make a meaningful contribution and survive in the academic community. There is a tendency to become overloaded with clinical shifts and bypass critical fellowship training years in favor of more appealing and lucrative junior faculty positions. It is time that we developed a comprehensive strategy to address this problem. We can direct
efforts at medical schools, residents-in-training, fellowships, and young faculty. Although we have made great strides in academics, much remains to be done.
Arthur B Sanders, MD, FACEP President, Society for Academic Emergency Medicine Lansing, Michigan 1. Sanders AB: Academic manpower shortage. Acad Emerg Meal 1989;1:1-2. 2. Sanders AB, Criss E, Witzke D, et al: Survey of undergraduate emergency medical education in the United States. Ann Emerg Meal 1986;15:1-5. 3. Association of American Medical Colleges: Medical Student Gradua tion Questionnaire. Washington, DC, AAMC, 1989. 4. Association of American Medical Colleges: Medical Studen~ Graduatio~ Questionnaire. Washington, DC, AAMC, 1988. 5. Association of American Medical Colleges: 1985 Medical Student Graduation Questionnaire: Subset report of respondents with emergency medicine as a definite specialty choice. A m J Emerg Med 1986;4:341-351. 6. Golden WE: Initial career choices of medical school honors graduates in the early 1970s and 1980s. Acad Med 1989;64:616-621.
The Need for Coding Systems to Evaluate Emergency Medicine Residency Programs In this issue of Annals, Langdorf, Strange, and Macneil provide a strong stimulus for emergency medicine educators to move to a more sophisticated and contemporary method of curriculum organization and evaluation. Their study is a description of the emergency department clinical experience of 33 emergency medicine residents at the PGI, II, and III levels, in three participating EDs of a m u l t i h o s p i t a l residency program, for nine months in 1987-1988. See related article, p 764 The relevance of the efforts of Langdorf et al can be summarized as follows. Organized emergency medicine should direct efforts to develop a coding strategy before requiring data registries for the purpose of comparing data between residency training programs, or for certification eligibility requirements. Variability exists among residents in the same program, in the number and variety of patients and conditions they evaluate. Consequently, monitoring of resident cases in the ED, as well as in all rotations, is useful and probably necessary. Education occurs in many locations and forms that should be integrated into any analysis of outcome. N E E D FOR A C O D I N G SYSTEM The major difficulty in interpreting and extrapolating information from this specific emergency medicine residency setting to emergency medicine training as a whole lies in the diagnostic coding used by the investigators. 144/827
Emergency medicine is a p r e d o m i n a n t l y sign- and symptom-driven specialty, rather than a diagnosis-driven one. Decision making in emergency medicine follows a logical sequence: triage and chief complaint --~ differential diagnosis --~ presumptive admitting or discharge diagnosis. The billing code (ICD-9) is not part of the physician's decision-making process. Difficulties in correlating ICD-9 coding with actual disease state have been identified. 1 In Langdorf's study, billing (ICD-9) codes have been further transformed into the American Board of Emergency Medicine-American College of Emergency Physicians Core C o n t e n t S t a t e m e n t (CCS) and the ACEP Length of Training Report (LOT), three distinct but not identical systems of disease organization. Furthermore, the CCS is a listing of signs, symptoms, diagnoses, pathophysiologic disorders, and technical, administrative, and interactive skills. The CCS was not devised to relate in any way to the ICD-9, or any coding system. The inability to transform actual clinical considerations into ICD-9, CCS, and LOT terms is one explanation for omissions of common entities. Other omissions, however, are hardly surprising because they are not commonly encountered in the ED: pneumoconioses, pituitary disorders, pertussis, Q fever, and trypanosomiasis. Thus, a simplification of emergency medicine decision making into a billing code may not be the most informative way for emergency medicine educators to assess or compare residency curricula and resident experiences. Complicating the coding system used by the investigators is the lack of clear, objective standards for the transformation of ICD-9 codes into CCS and LOT terms. Stan-
Annals of Emergency Medicine
19:7 July 1990
Several questions focused on research experience and plans. Thirty-nine percent of students going into emergency medicine participated in a research investigation compared with 47% of all graduating students in 1989. Twenty-one percent of students choosing emergency medicine in 1989 had authored a paper compared with 30% of all students. Research experience for students choosing emergency medicine was more common in 1989 than in 1985, when 30% of students were involved in a research project. In 1989, 12% of students entering emergency medicine said they planned a research fellowship after r e s i dency training compared with 6% in 1985. Although this represents an increase, it was still less than the 23% of all medical students in 1989 who said that their future plans included a research fellowship. Five percent of those going into emergency medicine in 1989 planned a research fellowship focusing on basic medical sciences. In 1985, none of the students planning a fellowship intended to focus on basic medical sciences. 3-s When students going into emergency medicine were asked about their career plans, 27% in 1989 and 19% in 1985 expressed a desire for a career in clinical science teaching and research compared with 29% of all medical students. Some students, however, may have unrealistic views of careers in academic emergency medicine. Although 27% wanted a career in academics, only 7% of students choosing emergency medicine said that they planned to be significantly involved in research involving at least 25% of their career time. In contrast, 15% of all students planned to be significantly involved in research.3-s Thus, students choosing emergency medicine enjoy the clinical aspects and diagnostic challenges. During the past five years, more students choosing emergency medicine expressed interest in academics. Many would like a career in academic emergency medicine but tend to be less interested in fellowship training and in being significantly involved with research than colleagues going into other specialties. It is important for students to understand that academic faculty must be truly involved in research and scholarly activities. As a specialty, we must be able to attract more students who are interested in emergency medicine research as a career. In a recent review of medical school honors graduates (AOA members) in 1982 and 1983 in nine of the top medical schools in the country, Golden found that emergency medicine was underweighted in the number of honors students choosing this specialty compared with other specialties. 6 This was somewhat surprising as our specialty is greatly oversubscribed and many of the residents selected are honors students. It is significant, however, that only two of these medical schools have residency training programs in emergency medicine, and none of the schools has an academic department or requires clerkships. During the next decade, it is essential that emergency medi-
Annals of Emergency Medicine
826/143
EDITORIALS
cine be established academically in all medical schools throughout the country. This is particularly important in the top ten to 20 medical schools, which will produce a significant percentage of clinical scientists and academic scholars. Faculty who teach emergency medicine to medical students, regardless of whether there is a residency training program, must be active researchers and scholars as well as clinicians. It is important for medical students who want a career in academics to view emergency medicine as a thriving academic discipline. Like all complex problems, there are no "quick-fix" solutions. In fact, the faculty shortage itself makes it difficult for young faculty to devote time and energy to acquiring the research and academic skills that are necessary to make a meaningful contribution and survive in the academic community. There is a tendency to become overloaded with clinical shifts and bypass critical fellowship training years in favor of more appealing and lucrative junior faculty positions. It is time that we developed a comprehensive strategy to address this problem. We can direct
efforts at medical schools, residents-in-training, fellowships, and young faculty. Although we have made great strides in academics, much remains to be done.
Arthur B Sanders, MD, FACEP President, Society for Academic Emergency Medicine Lansing, Michigan 1. Sanders AB: Academic manpower shortage. Acad Emerg Meal 1989;1:1-2. 2. Sanders AB, Criss E, Witzke D, et al: Survey of undergraduate emergency medical education in the United States. Ann Emerg Meal 1986;15:1-5. 3. Association of American Medical Colleges: Medical Student Gradua tion Questionnaire. Washington, DC, AAMC, 1989. 4. Association of American Medical Colleges: Medical Studen~ Graduatio~ Questionnaire. Washington, DC, AAMC, 1988. 5. Association of American Medical Colleges: 1985 Medical Student Graduation Questionnaire: Subset report of respondents with emergency medicine as a definite specialty choice. A m J Emerg Med 1986;4:341-351. 6. Golden WE: Initial career choices of medical school honors graduates in the early 1970s and 1980s. Acad Med 1989;64:616-621.
The Need for Coding Systems to Evaluate Emergency Medicine Residency Programs In this issue of Annals, Langdorf, Strange, and Macneil provide a strong stimulus for emergency medicine educators to move to a more sophisticated and contemporary method of curriculum organization and evaluation. Their study is a description of the emergency department clinical experience of 33 emergency medicine residents at the PGI, II, and III levels, in three participating EDs of a m u l t i h o s p i t a l residency program, for nine months in 1987-1988. See related article, p 764 The relevance of the efforts of Langdorf et al can be summarized as follows. Organized emergency medicine should direct efforts to develop a coding strategy before requiring data registries for the purpose of comparing data between residency training programs, or for certification eligibility requirements. Variability exists among residents in the same program, in the number and variety of patients and conditions they evaluate. Consequently, monitoring of resident cases in the ED, as well as in all rotations, is useful and probably necessary. Education occurs in many locations and forms that should be integrated into any analysis of outcome. N E E D FOR A C O D I N G SYSTEM The major difficulty in interpreting and extrapolating information from this specific emergency medicine residency setting to emergency medicine training as a whole lies in the diagnostic coding used by the investigators. 144/827
Emergency medicine is a p r e d o m i n a n t l y sign- and symptom-driven specialty, rather than a diagnosis-driven one. Decision making in emergency medicine follows a logical sequence: triage and chief complaint --~ differential diagnosis --~ presumptive admitting or discharge diagnosis. The billing code (ICD-9) is not part of the physician's decision-making process. Difficulties in correlating ICD-9 coding with actual disease state have been identified. 1 In Langdorf's study, billing (ICD-9) codes have been further transformed into the American Board of Emergency Medicine-American College of Emergency Physicians Core C o n t e n t S t a t e m e n t (CCS) and the ACEP Length of Training Report (LOT), three distinct but not identical systems of disease organization. Furthermore, the CCS is a listing of signs, symptoms, diagnoses, pathophysiologic disorders, and technical, administrative, and interactive skills. The CCS was not devised to relate in any way to the ICD-9, or any coding system. The inability to transform actual clinical considerations into ICD-9, CCS, and LOT terms is one explanation for omissions of common entities. Other omissions, however, are hardly surprising because they are not commonly encountered in the ED: pneumoconioses, pituitary disorders, pertussis, Q fever, and trypanosomiasis. Thus, a simplification of emergency medicine decision making into a billing code may not be the most informative way for emergency medicine educators to assess or compare residency curricula and resident experiences. Complicating the coding system used by the investigators is the lack of clear, objective standards for the transformation of ICD-9 codes into CCS and LOT terms. Stan-
Annals of Emergency Medicine
19:7 July 1990
