EDITORIALS
One of the real factors involved in physician burnout in emergency m e d i c i n e is that of c o n t i n u o u s conflict. W h e n the emergency physician has to agonize over such questions, it is f u r t h e r u n n e c e s s a r y s t r e s s t h a t adds to the i n c r e d i b l e h u m a n price paid by those who practice our prof e s s i o n . T h i s is an a r e a in w h i c h stress is t o t a l l y unnecessary. It w o u l d be an excellent project for each ACEP s t a t e c h a p t e r to m a k e c e r t a i n t h a t there are current statutes to resolve this simple consent issue. The great
e m e r g e n c y p h y s i c i a n deserves such legal backup; the mediocre emergency physician needs it. A b o v e all else, the m e s s a g e t h a t should be carried from the combinat i o n of T r e l o a r et al's a r t i c l e , case law, and the tenets of the Hippocratic O a t h is: Act! Act like the p a t i e n t is s o m e o n e you care about. Act like you have the courage and intelligence to tell the difference b e t w e e n n e c e s s a r y and u n n e c e s s a r y care and t e s t i n g and t h a t y o u have done for the patient what you would have
done for y o u r o w n f a m i l y m e m b e r . H a m l e t u n d e r s t o o d the p r o b l e m of t h i n k i n g too m u c h and acting too little: "Thus, the native hue of resolution is sicklied o'er w i t h the pale cast of thought . . . and lose the n a m e of action. ''3 - Caput deum!
Gregory L Henry, MD, FACEP Ann Arbor, Michigan 1. O'Brien v Cunard, SS Co. 154 Mass. 272, 28 N E 266. 2. H o l d e r AR: M i n o r s ' rights to c o n s e n t to m e d i c a l care. JAMA, 1987;257:3400. 3. W i l l i a m Shakespeare: Hamlet, III, i, 83.
The Future of Critical Care Medicine Within Emergency Medicine The ACEP Critical Care C o m m i t tee p o s i t i o n p a p e r " T h e F u t u r e of Critical Care Medicine W i t h i n Emergency M e d i c i n e " by A b r a m s o n and colleagues I is a comprehensive docum e n t t h a t addresses m a n y c o m p l e x issues regarding the relationship bet w e e n emergency m e d i c i n e and critical care m e d i c i n e . I n c l u d e d are discussions of practice issues as well as e d u c a t i o n a l and t r a i n i n g i s s u e s at both the residency and postresidency levels. I w i l l e m p h a s i z e w h a t I believe are the m o s t i m p o r t a n t positive aspects. Our value as emergency physicians to our c o m m u n i t i e s and our profession lies p r i m a r i l y in our a b i l i t y to r e s u s c i t a t e the c r i t i c a l l y ill and injured p a t i e n t s we e n c o u n t e r in the p r e h o s p i t a l and e m e r g e n c y d e p a r t m e n t settings. A l t h o u g h our efforts in providing p r i m a r y and urgent care are both useful and generally appreciated by our patients and colleagues, there should be no question in anyo n e ' s m i n d t h a t w e o w e o u r existence as a specialty to our ability to provide i m m e d i a t e , lifesaving care to our critically c o m p r o m i s e d patients. Therefore, it is i m p e r a t i v e t h a t our residency graduates be highly accomplished in the critical care skills required to assess and treat these patients. 156/320
The Committee's position paper points out that one third of our residency programs surveyed by the Society of Teachers of Emergency Medicine several years ago "were dissatisfied with their current ICU curriculum." Since that survey, many new residency programs in e m e r g e n c y m e d i c i n e have been established. Because I C U s t e n d to be c o m p l i c a t e d p o l i t i c a l e n v i r o n m e n t s , i t is safe to a s s u m e that critical care experience for emergency m e d i c i n e residents m a y be even less ideal in these newly developed programs. Therefore, it is i m p e r a t i v e t h a t w e act quickly to i m p l e m e n t the STEM reco m m e n d a t i o n s to i m p r o v e c r i t i c a l care training of our residents, w h i c h i n c l u d e d i n c r e a s i n g the t i m e s p e n t and the quality of the experience in b o t h a d u l t and p e d i a t r i c ICUs. T h e c o m m i t t e e ' s suggestions that we dev e l o p a core c u r r i c u l u m a n d b i b l i ography for critical care m e d i c i n e in emergency m e d i c i n e are excellent. Subspecialty postgraduate training in c r i t i c a l care m e d i c i n e for emergency physicians is urgently needed. T h e r a t i o n a l e for this t r a i n i n g is to develop a cadre of physicians w i t h i n the specialty of emergency m e d i c i n e w h o are c a p a b l e of p r o v i d i n g acad e m i c and clinical leadership in carAnnals of Emergency Medicine
ing for and studying the critically ill and i n j u r e d p a t i e n t s in the ED and prehospital phases of their illnesses. Fellowship-trained subspecialists could play a pivotal role w i t h i n their EDs in e s t a b l i s h i n g p r o t o c o l s for monitoring, resuscitating, and transporting these patients. It is u n l i k e l y that emergency physicians with critical care training w o u l d seek to b e c o m e i n - h o u s e int e n s i v i s t s p r o v i d i n g ongoing care in critical care units. Local hospital politics, rather than any n a t i o n a l policy, d e t e r m i n e w h o can obtain privileges for that role. However, the n u m b e r of individuals from emergency medicine w h o w o u l d s e e k such a career track w o u l d be so small as to m a k e it a nonissue. N o w t h a t the field of e m e r g e n c y m e d i c i n e has achieved p r i m a r y board status, it can d e v e l o p s u b s p e c i a l t y c e r t i f i c a t i o n . T h i s p r o c e s s w i l l enhance d e v e l o p m e n t as a specialty in areas such as emergency medical services, pediatric e m e r g e n c y medicine, toxicology, and transport medicine. I b e l i e v e critical care m e d i c i n e m u s t also be c o n s i d e r e d one of our m o s t i m p o r t a n t areas for subspecialty development. D u r i n g the p o l i t i c a l process leading to t h e d e c i s i o n to g r a n t e m e r gency m e d i c i n e p r i m a r y board status, 20:3 March 1991
EDITORIALS
the American Board of Emergency Medicine appears to have agreed not to pursue the development of critical care medicine as a subspeciahy of emergency medicine. I believe the thrust of this agreement was directed toward keeping emergency physicians from providing ongoing care to hospitalized patients. Critical care subspecialization for emergency physicians need not violate the intent of that agreement if those subspecial-
20:3 March 1991
ists were to confine their practices to the prehospital and ED settings. Critical care medicine has developed as a muhidisciplinary field. It has benefited tremendously from the unique perspectives of its surgeons, pediatricians, anesthesiologists, internists, nurses, bioengineers, and respiratory therapists. Emergency physicians have a unique perspective to contribute and must be welcomed by their colleagues who share an in-
Annals of Emergency Medicine
terest in caring for critically ill patients.
Jay L Falk, MD, FACEP, FCCM Emergency Medicine Residency Program Orlando Regional Medical Center, Orlando, Florida REFERENCE 1. Abramson NJ, Dellinger RP, Ehrlich FE, et al: The future of critical care medicine within emergency medicine. Ann Emerg Med 1990;19:832-835.
321/157
One of the real factors involved in physician burnout in emergency m e d i c i n e is that of c o n t i n u o u s conflict. W h e n the emergency physician has to agonize over such questions, it is f u r t h e r u n n e c e s s a r y s t r e s s t h a t adds to the i n c r e d i b l e h u m a n price paid by those who practice our prof e s s i o n . T h i s is an a r e a in w h i c h stress is t o t a l l y unnecessary. It w o u l d be an excellent project for each ACEP s t a t e c h a p t e r to m a k e c e r t a i n t h a t there are current statutes to resolve this simple consent issue. The great
e m e r g e n c y p h y s i c i a n deserves such legal backup; the mediocre emergency physician needs it. A b o v e all else, the m e s s a g e t h a t should be carried from the combinat i o n of T r e l o a r et al's a r t i c l e , case law, and the tenets of the Hippocratic O a t h is: Act! Act like the p a t i e n t is s o m e o n e you care about. Act like you have the courage and intelligence to tell the difference b e t w e e n n e c e s s a r y and u n n e c e s s a r y care and t e s t i n g and t h a t y o u have done for the patient what you would have
done for y o u r o w n f a m i l y m e m b e r . H a m l e t u n d e r s t o o d the p r o b l e m of t h i n k i n g too m u c h and acting too little: "Thus, the native hue of resolution is sicklied o'er w i t h the pale cast of thought . . . and lose the n a m e of action. ''3 - Caput deum!
Gregory L Henry, MD, FACEP Ann Arbor, Michigan 1. O'Brien v Cunard, SS Co. 154 Mass. 272, 28 N E 266. 2. H o l d e r AR: M i n o r s ' rights to c o n s e n t to m e d i c a l care. JAMA, 1987;257:3400. 3. W i l l i a m Shakespeare: Hamlet, III, i, 83.
The Future of Critical Care Medicine Within Emergency Medicine The ACEP Critical Care C o m m i t tee p o s i t i o n p a p e r " T h e F u t u r e of Critical Care Medicine W i t h i n Emergency M e d i c i n e " by A b r a m s o n and colleagues I is a comprehensive docum e n t t h a t addresses m a n y c o m p l e x issues regarding the relationship bet w e e n emergency m e d i c i n e and critical care m e d i c i n e . I n c l u d e d are discussions of practice issues as well as e d u c a t i o n a l and t r a i n i n g i s s u e s at both the residency and postresidency levels. I w i l l e m p h a s i z e w h a t I believe are the m o s t i m p o r t a n t positive aspects. Our value as emergency physicians to our c o m m u n i t i e s and our profession lies p r i m a r i l y in our a b i l i t y to r e s u s c i t a t e the c r i t i c a l l y ill and injured p a t i e n t s we e n c o u n t e r in the p r e h o s p i t a l and e m e r g e n c y d e p a r t m e n t settings. A l t h o u g h our efforts in providing p r i m a r y and urgent care are both useful and generally appreciated by our patients and colleagues, there should be no question in anyo n e ' s m i n d t h a t w e o w e o u r existence as a specialty to our ability to provide i m m e d i a t e , lifesaving care to our critically c o m p r o m i s e d patients. Therefore, it is i m p e r a t i v e t h a t our residency graduates be highly accomplished in the critical care skills required to assess and treat these patients. 156/320
The Committee's position paper points out that one third of our residency programs surveyed by the Society of Teachers of Emergency Medicine several years ago "were dissatisfied with their current ICU curriculum." Since that survey, many new residency programs in e m e r g e n c y m e d i c i n e have been established. Because I C U s t e n d to be c o m p l i c a t e d p o l i t i c a l e n v i r o n m e n t s , i t is safe to a s s u m e that critical care experience for emergency m e d i c i n e residents m a y be even less ideal in these newly developed programs. Therefore, it is i m p e r a t i v e t h a t w e act quickly to i m p l e m e n t the STEM reco m m e n d a t i o n s to i m p r o v e c r i t i c a l care training of our residents, w h i c h i n c l u d e d i n c r e a s i n g the t i m e s p e n t and the quality of the experience in b o t h a d u l t and p e d i a t r i c ICUs. T h e c o m m i t t e e ' s suggestions that we dev e l o p a core c u r r i c u l u m a n d b i b l i ography for critical care m e d i c i n e in emergency m e d i c i n e are excellent. Subspecialty postgraduate training in c r i t i c a l care m e d i c i n e for emergency physicians is urgently needed. T h e r a t i o n a l e for this t r a i n i n g is to develop a cadre of physicians w i t h i n the specialty of emergency m e d i c i n e w h o are c a p a b l e of p r o v i d i n g acad e m i c and clinical leadership in carAnnals of Emergency Medicine
ing for and studying the critically ill and i n j u r e d p a t i e n t s in the ED and prehospital phases of their illnesses. Fellowship-trained subspecialists could play a pivotal role w i t h i n their EDs in e s t a b l i s h i n g p r o t o c o l s for monitoring, resuscitating, and transporting these patients. It is u n l i k e l y that emergency physicians with critical care training w o u l d seek to b e c o m e i n - h o u s e int e n s i v i s t s p r o v i d i n g ongoing care in critical care units. Local hospital politics, rather than any n a t i o n a l policy, d e t e r m i n e w h o can obtain privileges for that role. However, the n u m b e r of individuals from emergency medicine w h o w o u l d s e e k such a career track w o u l d be so small as to m a k e it a nonissue. N o w t h a t the field of e m e r g e n c y m e d i c i n e has achieved p r i m a r y board status, it can d e v e l o p s u b s p e c i a l t y c e r t i f i c a t i o n . T h i s p r o c e s s w i l l enhance d e v e l o p m e n t as a specialty in areas such as emergency medical services, pediatric e m e r g e n c y medicine, toxicology, and transport medicine. I b e l i e v e critical care m e d i c i n e m u s t also be c o n s i d e r e d one of our m o s t i m p o r t a n t areas for subspecialty development. D u r i n g the p o l i t i c a l process leading to t h e d e c i s i o n to g r a n t e m e r gency m e d i c i n e p r i m a r y board status, 20:3 March 1991
EDITORIALS
the American Board of Emergency Medicine appears to have agreed not to pursue the development of critical care medicine as a subspeciahy of emergency medicine. I believe the thrust of this agreement was directed toward keeping emergency physicians from providing ongoing care to hospitalized patients. Critical care subspecialization for emergency physicians need not violate the intent of that agreement if those subspecial-
20:3 March 1991
ists were to confine their practices to the prehospital and ED settings. Critical care medicine has developed as a muhidisciplinary field. It has benefited tremendously from the unique perspectives of its surgeons, pediatricians, anesthesiologists, internists, nurses, bioengineers, and respiratory therapists. Emergency physicians have a unique perspective to contribute and must be welcomed by their colleagues who share an in-
Annals of Emergency Medicine
terest in caring for critically ill patients.
Jay L Falk, MD, FACEP, FCCM Emergency Medicine Residency Program Orlando Regional Medical Center, Orlando, Florida REFERENCE 1. Abramson NJ, Dellinger RP, Ehrlich FE, et al: The future of critical care medicine within emergency medicine. Ann Emerg Med 1990;19:832-835.
321/157
