A Brief History of Emergency Medicine Residency Training

A Brief History of Emergency Medicine Residency Training

By Brian J. Zink, MD, Associate Professor, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI

The history of Emergency Medicine residency training is interwoven with the push for specialty status in Emergency Medicine in the late 1960's and 1970's. By the mid-1960's, the number of American physicians who were specialists was rapidly rising, and the number of general practitioners was declining. Hospitals were becoming more modernized and technologically advanced. These forces in medicine, along with demographic and social changes, caused the public to increasingly rely on hospital emergency rooms for care. Unfortunately, the medical expertise and a system for providing quality emergency care were sorely lacking. In other medical fields, scientific discovery and academic growth were prerequisites for new types of medical service. This was not the case with Emergency Medicine, where public demand, more than science, fueled the formation of a new specialty.

In 1961, James Mills, Jr., MD, and three colleagues started a full-time Emergency Medicine practice in Alexandria, Virginia. By the late 1960's, hundreds of "Emergency Physicians" were in practice across the U.S. In 1968, John Wiegenstein, MD, and other founders organized Emergency Physicians to form the American College of Emergency Physicians (ACEP). Over the next decade, ACEP was the driving force in moving the field toward Board specialty status. The early leaders of the field who first left their practices to work full time in Emergency Departments recognized the need for training in Emergency Medicine. This began first as CME-type meetings, or month-long courses at academic medical centers, but it became apparent the only way to properly train Emergency Physicians was through a formal residency program.

The first institution to act was the University of Cincinnati. Due to an increasing ED patient volume (over 100,000 patients per year) and complaints from faculty and the public about quality of care, leaders at the Cincinnati General Hospital decided something needed to be done with "the problem in the E.R.[1] " A young internist, Herbert Flessa, MD, was charged with improving emergency care. Flessa believed that a training program would put more residents in the ED and perhaps ameliorate some of the problems. Flessa applied to the AMA to start a two year residency in Emergency Medicine (after a rotating internship). The AMA was reluctant, and the residency was actually approved as a program under family practice, with a certificate of special training in Emergency Medicine. Nonetheless, the program was promoted as an Emergency Medicine residency, and Bruce Janiak, MD, became the first Emergency Medicine resident in 1970. The training program was far different from that experienced by today's Emergency Medicine residents. Only two of the 24 months of training were actually spent in the ED. This was partly due to the belief that Emergency Medicine concepts were best taught by experts in other specialties, and the fact that almost no faculty were available to teach residents. In that era, ED's were strictly the domain of residents and interns, and faculty rarely ventured in to this environment.

Shortly after Cincinnati got started, other institutions independently formed programs. David Wagner, who started the next Emergency Medicine residency at the Medical College of Pennsylvania (MCP), describes the early Emergency Medicine residents as "wagon train riders" - people who "would have jumped on a covered wagon and gone West 100 years earlier.[2"] Wagner, who was trained and practiced as a pediatric surgeon, served as Director of Emergency Services at MCP. He saw how Emergency Medicine was expanding in community hospitals, and started to think about training physicians in "acute care." He eventually developed his ideas into the first three year residency in Emergency Medicine. Wagner's first recruit was Pamela Bensen, MD, who, as a pregnant senior medical student, traveled to the AMA to lobby for the creation of the residency program she hoped to join. The program was eventually approved, and Bensen started in 1971. She found, like her Cincinnati counterparts, that she had to explain to residents and physicians in other fields what she was doing. Her function on off-service rotations was determined by her own assessment of what she needed to learn.

A few months behind MCP was a new program at Los Angeles County, University of Southern California Medical Center (LAC/USC). The "Big County," stressed to the limits by the same factors that had increased emergency visits across the country, was handling a thousand emergency patients a day. Gail V. Anderson, MD, director of obstetrics and gynecology at LAC/USC Medical Center, was asked to head up the ED and petitioned the USC medical school for academic department status. To his surprise, this was granted, and Anderson became the first Chairman of the first Department of Emergency Medicine in a U.S. medical school in October of 1971. A residency started there at the same time.

The next residency to get off the ground was in 1972 at the University of Louisville, where the second academic Department of Emergency Medicine was created. Shortly after this, Peter Rosen, MD, another surgeon who converted to Emergency Medicine, formed a residency at the University of Chicago. Over the next three years, residencies sprang up around the country. By 1975, there were 31 residencies, half of them in the Midwest, but few of the renowned medical schools had approved Emergency Medicine residencies. A fledgling organization, EMRA, formed in 1974 to serve Emergency Medicine residents.

The early Emergency Medicine residents invariably found teaching in the ED to be sparse or non-existent. They learned by seeing countless patients, through trial and error. When they rotated on other services, they were viewed as oddities, and no one could understand why they were choosing to train in an unrecognized medical field. The path to recognition lay in the politics of organized medicine. ACEP had developed "Proposed Essentials of a Residency Training Program in Emergency Medicine" as early as 1970, but it took three years to have this approved by the AMA. A key point in the fight for legitimacy was a meeting organized by the AMA in 1973 - the Conference on Education of the Physician in Emergency Medical Care. Many organizations, government agencies, and the other major medical specialties were represented. The participants debated whether Emergency Medicine residencies were needed and if Emergency Medicine was truly a specialty. The critical end result was a report in favor of Emergency Medicine residency training, and an unwritten understanding that Emergency Medicine was on its way to officially becoming a specialty. Although it seemed interminable to those who did the dirty work, it was only six years later, in 1979, that the American Board of Emergency Medicine was approved by the American Board of Medical Specialties. After this, a green light was on for the development of many more residencies, an official approval system for residencies, and the academic infrastructure of the field.

Unlike the residents of today, those physicians who pursued Emergency Medicine residency training in the early 1970's faced an uncertain future. They had no opportunity to be certified by a specialty board, and had no guarantee their chosen field would persist. They were pioneers and mavericks in spirit and action. And despite the severe lack of teachers, curricula, and resources, they managed to learn and become leaders by relying on each other. As Phillip Buttaravoli, MD, an early Emergency Medicine resident at the University of Cincinnati remembers,

"I still thought I got excellent education and there was an enormous camaraderie. We were different than everybody else. We were the soldiers of fortune that were trying to battle our way within this big medical center. Nobody understood who we were, what we were doing. So we had an enormous bond." [3]

Note: Elements of this article are derived from Dr. Zink's book: Anyone, Anything, Anytime-A History of Emergency Medicine, which is in publication, due out in the fall of 2005.

References:

1. Flessa, H., Interview of Herbert Flessa, M.D. by Brian Zink. 2002: Cincinnati, Ohio.
2. Wagner, D., Interview of David Wagner by Brian Zink. 2003, Philadelphia, PA.
3. Buttaravoli, P., Interview of Phillip Buttaravoli, M.D. by Brian Zink. 2003: West Palm Beach, Florida.

Abridged article published in February/March 2005 EM Resident.