1. 
   

   What performance gaps led to the emergence of Emergency Medicine (EM) as an independent specialty?

   
   
2. 
   

   What training do emergency physicians receive during residency, and what subspecialties are available after training?

   
   
3. 
   

   In what ways do Emergency Medicine and Hospital Medicine interact with respect to triage, patient flow, performance measures, comanagement, and care transitions?

   
   
4. 
   

   What is the Emergency Medical Treatment and Active Labor Act (EMTALA), and how does it govern aspects of Emergency Medicine and Hospital Medicine practice?

The American Board of Medical Specialties describes the practice of Emergency Medicine as focusing on the immediate decision making and action necessary to prevent death or any further disability both in the prehospital setting and in the emergency department (ED) by providing immediate recognition, evaluation, care, stabilization, and disposition of a generally diverse population of adult and pediatric patients in response to acute or episodic illness and injury. Emergency Medicine and Hospital Medicine share many common aspects, and, because many of the patients who will be admitted to the hospitalist service will begin their inpatient care from the ED, it is important for both specialties to have an in-depth understanding of each other’s domain, scope of practice, areas of expertise, and foundation in order to provide seamless and integrated patent care.

Emergency Medicine, much like Hospital Medicine, is a specialty that has significant overlap with many other specialties in that it is not a system or procedure-specific specialty but one that specializes in situational presentation of disease. Emergency Medicine is the initial management of any disease that may present in an acute or episodic manner, including acute manifestations of chronic diseases. The value of having a specific specialist available to care for patients emergently during the crucial “golden hour” of injury was first envisioned during the Korean War in the 1950s. Although it is difficult to envision a time when EDs were staffed by junior, untrained, rotating physicians, this was the case as recently as the 1960s and ’70s and still persists in other countries. Prior to the 1960s and ’70s, any manner of specialty would be assigned to “cover” the ED on a rotational basis as part of a physician’s obligation to a hospital. In teaching hospitals, this rotation was often relegated to very junior trainees who would then contact more senior trainees depending on their perceived need.

Beginning in the early 1970s, groups of physicians began to leave private practice to devote all of their clinical work to the ED. The first of these groups was based in Alexandria, Virginia, and their plan, known as the Alexandria Plan, was to provide consistent attending-level emergency care 24/7 year-round by physicians whose only practice was Emergency Medicine. Soon after, the first Emergency Medicine training program was established at Cincinnati General Hospital in 1970, with several other residency programs following suit. With the establishment of the American College of Emergency Physicians (ACEP) there was recognition of Emergency Medicine training programs by the American Medical Association (AMA) and the American Osteopathic Association (AOA). In 1979 the American Board of Medical Specialties recognized Emergency Medicine as a specialty, and the American Board of Emergency Medicine was formed. Initially, there were two paths to board certification in Emergency Medicine; the practice path, which allowed physicians with significant experience in Emergency Medicine to sit for the boards, and residency training in Emergency Medicine. The practice pathway closed in 1990. Approximately 40,000 physicians currently practice Emergency Medicine in the United States, with 152 Emergency Medicine residencies graduating 1500 emergency physicians per year.

In 1975, the American College of Emergency Physicians and the University Association for Emergency Medicine, now the Society for Academic Emergency Medicine (SAEM), conducted a practice analysis of the emerging field of Emergency Medicine essentially producing an overview of common conditions, symptoms, and diseases that present to EDs. After multiple revisions and reorganizations, this initiative become the core content task force, culminating in an in-depth analysis of the clinical practice of Emergency Medicine and producing Core Content of Emergency Medicine—the Model of the Clinical Practice of Emergency Medicine (EM Model) (Table 120-1).

The most recent (2009) model of Emergency Medicine practice delineates (1) an assessment of patient acuity, (2) a description of the tasks that must be performed to provide appropriate emergency medical care, and (3) a listing of common conditions, symptoms, and disease presentations. This model represents the essential information and skills necessary for the clinical practice of Emergency Medicine by board-certified emergency physicians.

Three formats of Emergency Medicine residency training are available: a) 3 years of Emergency Medicine, b) 1 year preliminary or transitional internship followed by 3 years of Emergency Medicine, and c) 4 years of Emergency Medicine. The American Board of Emergency Medicine requires a minimum of 3 years of training to qualify candidates to sit for the board examination process, and the 3-year training program format remains the most common. This is consistent with the Centers for Medicare and Medicaid Services (CMS) funding for graduate medical education (GME) programs in Emergency Medicine. Some institutions offer a 5-year dual training program of Emergency Medicine/internal medicine, Emergency Medicine/Family Medicine or Emergency Medicine/Pediatrics. Wide curricular variation exists among Emergency Medicine residency programs, although most have a high concentration of intensive care unit and trauma rotations in addition to Emergency Medicine, with some programs sending their residents to train within a variety of off-service rotations (including inpatient internal medicine wards), whereas others train their residents in the ED for the majority of their residency. The Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Emergency Medicine (RRC-EM) does not require experience in inpatient internal medicine wards curriculum (Table 120-2).

Emergency Medicine has become a competitive specialty in the National Residency Match Program (NRMP), with a > 99% fill rate every year since 1995. A number of ACGME-accredited and nonaccredited subspecialty fellowships are available for candidates who have completed Emergency Medicine residency training (Table 120-3). Some graduates of these programs go on to practice in both fields, splitting their time between Emergency Medicine and their subspecialty, but they all have the opportunity to bring their newfound expertise and perspective back to their practice of Emergency Medicine. This is especially advantageous for dual-trained physicians who have the opportunity to practice both Emergency Medicine and Hospital Medicine, further bridging the two specialties and extending collaboration.

Resuscitation

The practice of Emergency Medicine is broad and requires an expansive understanding of the emergent and urgent presentations of many disease processes, central to which is recognizing and stabilizing acute life-threatening conditions. Despite the public perception that the many patients who present to an ED are nonurgent, recent publications have described that less than 15% of ED patients are actually nonurgent. As a group, ED patients have higher acuity and greater potential for morbidity and poor prognosis than patients presenting to other outpatient settings.