address to the first european congress on emergency medicine

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ACADEMIC EMERGENCY MEDICINE • March 1999, Volume 6, Number 3 169 times). Am J Emerg Med. 1993; 11: 84–9. 2. Paine J. The history of the invention and development of the gastrointestinal tube. In: Cantor MO (ed). Intestinal In- tubation. Springfield, IL: Charles C Tho- mas, 1949, pp 16 – 39. 3. Nott MR, Hughes JH. Topical anaes- thesia for the insertion of nasogastric tubes. Eur J Anaesthesiol. 1995; 12:287 90. 4. Singer AJ, Richman PB, LaVefre R, et al. Comparison of patient and practi- tioner assessments of pain from com- monly performed emergency department procedures [abstract]. Acad Emerg Med. 1997; 4:404 – 5. 5. Singer AJ, Konia N. Comparison of topical anesthetics and vasoconstrictors vs lubricants prior to nasogastric intu- bation: a randomized, controlled trial. Acad Emerg Med. 1999; 6:184 – 90. 6. Max MB, Laska EM. Single-dose an- algesic comparisons. In: Max MB, Por- tenoy RK, Laska EM, (eds). Advances in Pain Research and Therapy, Volume 18. New York: Raven Press, 1991, p 72. 7. Maglinte DD, Lappas JC, Chernish clysis by use of sedation. AJR Am J Roentgenol. 1988; 151:951 – 2. 8. Maglinte DD, Stevens LH, Hall RC, et al. Dual-purpose tube for enteroclysis and nasogastric–nasoenteric decompres- sion. Radiology. 1992; 185:281–2. 9. Bender GN, Maglinte DDT. Small bowel obstruction: the need for greater radiologist involvement [editorial]. Emerg Radiol. 1997; Nov/Dec:1 – 3. 10. Maglinte DD, Kelvin FM, Micon LT, et al. Nasointestinal tube for decompres- sion or enteroclysis: experience with 150 patients. Abdom Imaging. 1994; 19: 108 – 12. 11. Mucha P Jr. Small intestinal ob- struction. Surg Clin North Am. 1987; 67: 597 – 620. 12. Wolfson PJ, Bauer JJ, Gelernt IM, et al. Use of the long tube in the manage- ment of patients with small-intestinal obstruction due to adhesions. Arch Surg. 1985; 120:1001 – 6. 13. Morgenstern L. Whatever happened to the long tube? [editorial]. Am J Surg. 1995; 170:237. 14. Paine J. The role of gastrointestinal decompression in surgery. Surgery. 1936; 33:995 – 1020. Address to the First European Congress on Emergency Medicine Editor’s Note: This address was delivered by John Marx, MD, to the First European Congress on Emergency Medicine, held in San Marino, Italy, in April 1998. Dr. Marx was the invited keynote speaker for the conference, and is currently the chair of the Depart- ment of Emergency Medicine at Carolinas Medical Center. Dr. Marx is the immediate past pres- ident of SAEM. I n the spring of my last medi- cal school year at Stanford, I took an elective rotation in emer- gency medicine (EM) at the county hospital in San Francisco. There I breathed for the very first time the quintessential va- pors of what we are all about, what we see and what we do. It was quite simply a slice of life, the term by which I long ago be- gan to describe EM. It was barely-controlled chaos in a med- ical setting. Across the threshold came patients with every imag- inable and unimaginable illness and injury at any point through- out the entire spectrum of dis- ease. And the patients presented in undifferentiated fashion, that is, without a preformed diagno- sis, requiring that we, the phy- sicians, make critical decisions, that we, the physicians per- form critical procedures, that we, the physicians act upon just a very few hard-earned data in order to intervene providently in their lives. For a student who on previous rotations always had known the diagnosis well in ad- vance, who always had the lei- sure of reading up on the subject well before venturing into the patient’s room, who always could wait to decide carefully what was appropriate before writing the orders, this was a completely new experience. And it was very intoxicating. For the first time, I felt like a real doctor. In July 1978, after having completed one year of internal medicine training, I matricu- lated into an EM program in Denver, Colorado. I was the only one among our group to have gone only through internship, the first year of training. The rest had been further along in specialty training or were out practicing in internal medicine, surgery, family medicine, or even in an ED, but without formal training. Each had been unfulfil- led and was willing to venture into this brand new discipline. Emergency medicine was not yet a specialty, per se. It was still a fledging undertaking. The clin- ical practice of EM began in the United States in 1961 when four individuals joined together in Virginia to provide full-time ED coverage under what was known as the Alexandria plan. In 1968, the American College of Emer- gency Physicians (ACEP) was founded by eight physicians and in 1970, the first few residency training programs were born. Our academic footholds began mostly in community or public hospitals, away from the stran- glehold of the high-profile medi- cal centers with their powerful and condemning departments of medicine and surgery. In those places, it was especially difficult to insert ourselves into the exist- ing fiefdoms. The mission of EM was not understood and the ef- fort was viewed as an encroach- ment. Indeed, it has only been in the last ten years that successful EM programs have taken root in places such as Stanford, Har- vard, and Yale, but there remain, even today, a number of medical center holdouts. Understand that we have had no shortage of detractors, to be sure, quick to inform us that this was a misappropriation of talent, a waste of time, and a certain journey of unhappiness, stress, and burnout. But, I had the won- derful fortune of serving under the mentorship of Dr. Peter Ro- sen, one who understood what our field was about (for I cer- tainly did not), who anticipated what was required for it to be

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ACADEMIC EMERGENCY MEDICINE • March 1999, Volume 6, Number 3 169

times). Am J Emerg Med. 1993; 11:84–9.2. Paine J. The history of the inventionand development of the gastrointestinaltube. In: Cantor MO (ed). Intestinal In-tubation. Springfield, IL: Charles C Tho-mas, 1949, pp 16–39.3. Nott MR, Hughes JH. Topical anaes-thesia for the insertion of nasogastrictubes. Eur J Anaesthesiol. 1995; 12:287–90.4. Singer AJ, Richman PB, LaVefre R, etal. Comparison of patient and practi-tioner assessments of pain from com-monly performed emergency departmentprocedures [abstract]. Acad Emerg Med.1997; 4:404–5.5. Singer AJ, Konia N. Comparison oftopical anesthetics and vasoconstrictorsvs lubricants prior to nasogastric intu-bation: a randomized, controlled trial.Acad Emerg Med. 1999; 6:184–90.6. Max MB, Laska EM. Single-dose an-algesic comparisons. In: Max MB, Por-tenoy RK, Laska EM, (eds). Advances inPain Research and Therapy, Volume 18.New York: Raven Press, 1991, p 72.7. Maglinte DD, Lappas JC, Chernish

clysis by use of sedation. AJR Am JRoentgenol. 1988; 151:951–2.8. Maglinte DD, Stevens LH, Hall RC,et al. Dual-purpose tube for enteroclysisand nasogastric–nasoenteric decompres-sion. Radiology. 1992; 185:281–2.9. Bender GN, Maglinte DDT. Smallbowel obstruction: the need for greaterradiologist involvement [editorial].Emerg Radiol. 1997; Nov/Dec:1–3.10. Maglinte DD, Kelvin FM, Micon LT,et al. Nasointestinal tube for decompres-sion or enteroclysis: experience with 150patients. Abdom Imaging. 1994; 19:108–12.11. Mucha P Jr. Small intestinal ob-struction. Surg Clin North Am. 1987; 67:597–620.12. Wolfson PJ, Bauer JJ, Gelernt IM, etal. Use of the long tube in the manage-ment of patients with small-intestinalobstruction due to adhesions. Arch Surg.1985; 120:1001–6.13. Morgenstern L. Whatever happenedto the long tube? [editorial]. Am J Surg.1995; 170:237.14. Paine J. The role of gastrointestinaldecompression in surgery. Surgery. 1936;33:995–1020.

Address to the First European Congress onEmergency Medicine

Editor’s Note: This address wasdelivered by John Marx, MD, tothe First European Congress onEmergency Medicine, held in SanMarino, Italy, in April 1998. Dr.Marx was the invited keynotespeaker for the conference, and iscurrently the chair of the Depart-ment of Emergency Medicine atCarolinas Medical Center. Dr.Marx is the immediate past pres-ident of SAEM.

In the spring of my last medi-cal school year at Stanford, I

took an elective rotation in emer-gency medicine (EM) at thecounty hospital in San Francisco.There I breathed for the veryfirst time the quintessential va-pors of what we are all about,what we see and what we do. Itwas quite simply a slice of life,the term by which I long ago be-gan to describe EM. It wasbarely-controlled chaos in a med-ical setting. Across the thresholdcame patients with every imag-inable and unimaginable illness

and injury at any point through-out the entire spectrum of dis-ease. And the patients presentedin undifferentiated fashion, thatis, without a preformed diagno-sis, requiring that we, the phy-sicians, make critical decisions,that we, the physicians per-form critical procedures, thatwe, the physicians act upon justa very few hard-earned data inorder to intervene providentlyin their lives. For a student whoon previous rotations always hadknown the diagnosis well in ad-vance, who always had the lei-sure of reading up on the subjectwell before venturing into thepatient’s room, who always couldwait to decide carefully what wasappropriate before writing theorders, this was a completelynew experience. And it was veryintoxicating. For the first time, Ifelt like a real doctor.

In July 1978, after havingcompleted one year of internalmedicine training, I matricu-lated into an EM program in

Denver, Colorado. I was the onlyone among our group to havegone only through internship,the first year of training. Therest had been further along inspecialty training or were outpracticing in internal medicine,surgery, family medicine, or evenin an ED, but without formaltraining. Each had been unfulfil-led and was willing to ventureinto this brand new discipline.

Emergency medicine was notyet a specialty, per se. It was stilla fledging undertaking. The clin-ical practice of EM began in theUnited States in 1961 when fourindividuals joined together inVirginia to provide full-time EDcoverage under what was knownas the Alexandria plan. In 1968,the American College of Emer-gency Physicians (ACEP) wasfounded by eight physicians andin 1970, the first few residencytraining programs were born.Our academic footholds beganmostly in community or publichospitals, away from the stran-glehold of the high-profile medi-cal centers with their powerfuland condemning departments ofmedicine and surgery. In thoseplaces, it was especially difficultto insert ourselves into the exist-ing fiefdoms. The mission of EMwas not understood and the ef-fort was viewed as an encroach-ment. Indeed, it has only been inthe last ten years that successfulEM programs have taken root inplaces such as Stanford, Har-vard, and Yale, but there remain,even today, a number of medicalcenter holdouts.

Understand that we have hadno shortage of detractors, to besure, quick to inform us that thiswas a misappropriation of talent,a waste of time, and a certainjourney of unhappiness, stress,and burnout. But, I had the won-derful fortune of serving underthe mentorship of Dr. Peter Ro-sen, one who understood whatour field was about (for I cer-tainly did not), who anticipatedwhat was required for it to be

170 COMMENTARIES Marx • FIRST EUROPEAN CONGRESS ON EM

successful, and who was willingto challenge the icons, stand be-fore the slung arrows, and wieldhis own battle implements tocarve out turf and cordon offpatients to be cared for by ourhousestaff in a primary andmeaningful fashion.

The next step was enlighten-ment. In 1979, EM received offi-cial recognition as a specialty.This meant that we began torequire that physicians satisfyboth written and oral examina-tions in order to become board-certified in EM. And, in 1988there was closure of the practicetrack, which, between 1979 andthat year, had allowed physi-cians with sufficient clinical ex-perience in EDs to sit for theboards. From that time on, onlythose who had and will havetrained in a formal and approvedresidency training program wereand will be permitted to becomeboard-certified in the specialty ofEM.

And what is the currentstatus of the field in the UnitedStates? We have approximately120 training programs and 50recognized departments of EM inU.S. medical schools. However, Imust note that still, only 50–60% of available EM clinical po-sitions are held by board-certi-fied emergency physicians (EPs).Happily, virtually every aca-demic position on this country’sEM faculties is occupied by aman or a woman who has trainedand is board-certified in EM.

Our established academic so-

ciety, the Society for AcademicEmergency Medicine (SAEM),began in the mid-1970s, and nownearly 5,000 physicians and re-searchers in our field are mem-bers. Within EM, we have fourpeer-reviewed journals, manytextbooks, and active, substan-tive research programs acrossthe country. Since the genesis ofthe academic component of ourspecialty, more than 25 yearsago, it has been the strong desirethat we construct a competentknowledge base that would serveas the foundation of our clinicalpractice, our teaching and ourfurther research efforts.

But we have our problems.The ’70s were the nascence pe-riod, the ’80s one of growth, andnow, in the ’90s, it is one of‘‘rightsizing.’’ Diminishing fund-ing from our government and theprivate sector has caused terrificconcern for all of academic med-icine, not simply academic EM.We chairs now spend a goodamount of our time trying to con-vince administrators, those whohold the purse strings, of what isso obvious to us—the rightnessof our purpose, our organiza-tional skills and gatekeeper effi-ciency, and our ability to deliversuperior care at a lesser cost.But, it is a difficult task.

Please forgive the intimacy ofmy story. It is not an unusualone for those of us second-gen-eration EPs who literally grewalongside the specialty. And it isa story with a happy ending andI believe has commonality across

geographic borders. What wehave struggled through andwhat we continue to face in ourcountry will likely be found inthe stories you are creating rightnow in yours. May I congratulateyou on your efforts and wish youcontinued success. And, may I re-mind all of us in academic EMthat our most fundamental im-perative shall remain the same.We must make clear to our col-leagues outside of EM, and, moreimportantly, we must instill inthe residents whom we teach,that EM has a unique biologyand that this unique biologyis best understood by and mustbe practiced and taught byEPs.

I am deeply grateful for andtremendously honored by the in-vitation to speak at the com-memoration of your academicconference. May I especiallythank Professors Manni and De-looz, the conference planningcommittee, the European Societyfor Emergency Medicine, theEuropean Center for DisasterMedicine, the former Presidentof Italy, Francesco Cosiglia, myesteemed colleagues on this po-dium, and all of you for your in-dulgence. Grazie tonto. Thankyou so much.—JOHN A. MARX,MD, Department of EmergencyMedicine, Carolinas Medical Cen-ter, Charlotte, NC

Key words. First European Con-gress on Emergency Medicine; key-note address; emergency medicine;academic emergency medicine.