address to the first european congress on emergency medicine
TRANSCRIPT
ACADEMIC EMERGENCY MEDICINE • March 1999, Volume 6, Number 3 169
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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.