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P&S Journal

P&S Journal: Spring 1996, Vol.16, No.2
Emergency Medicine at P&S

By George Hunka

Although emergency medicine has existed since injuries first sent humans to health care professionals, emergency medicine as a defined medical specialty is a fairly recent development. In the 16-year period between 1955 and 1971, visits to emergency rooms increased by 367 percent, and it wasn't until that postwar period that emergency medicine physicians gave serious thought to their work as a specialty.
Dr. Neal M. Shipley in an emergency room that could have ER residents next year.

The American College of Emergency Physicians was founded in 1968 as the first professional society dedicated to the needs of emergency physicians and to academic programs devoted to the field. In 1979, 11 years later, the American Medical Association and the American Board of Medical Specialists recognized emergency medicine as an official medical specialty.

The years since have seen growth in the specialty as an academic curriculum, but progress has been slow. A 1993 AMA study found that only 39 schools granting M.D. degrees (35 percent of the total) had a separate Department of Emergency Medicine. Also, the emergency medicine skills taught in these institutions varied widely from school to school. For example, 81 percent of medical schools required basic life support/CPR training, but only 24 percent required knowledge of cervical spine immobilization.

P&S is among the 65 percent of schools without an emergency medicine department (emergency medicine is a division within the Department of Medicine), but that may change if Dr. Neal M. Shipley, assistant clinical professor of medicine, has his way. The first step is a residency training program in emergency medicine. Dr. Shipley, working closely with Dr. Thomas Q. Morris, vice dean of the Faculty of Medicine; Dr. Allen I. Hyman, executive vice president and chief of staff of Presbyterian Hospital; and Dr. Brenda J. Merritt, assistant professor of clinical medicine and the hospital's director of emergency medicine, submitted a proposal for an emergency medicine residency to the Residency Review Committee of the Accreditation Council for Graduate Medical Education in December 1995.

"It takes nine months from the date of submission to receive a response. It's something like having a baby," Dr. Shipley says. "They'll send a site inspector, who will come and inspect our physical plant, speak to myself, Dr. Merritt, other faculty, and residents who have worked here, and speak to the heads of all the major departments. Basically, they'll look under the carpet to see if we can provide residents with a good environment for teaching. Then, in September 1996, we'll hear from the ACGME. If we receive approval then, we'll recruit residents for a start date of July 1, 1997."

The genesis of an emergency medicine residency stemmed from the hospital's recognition that emergency care needed improvement, Dr. Shipley explains. "The perception on the hospital's part was that its emergency department was a little bit out of control and chaotic, that there were too many walk-outs, that is, patients who register and disappear because the wait's too long. So the hospital was looking for a way to fix the place."

The hospital approached Dr. Merritt, who ran the emergency department at the Allen Pavilion, for assistance. "Her response was that they needed to bring in academic faculty and start an emergency medicine residency training program. It was felt that the best way to provide better quality care to a greater number of patients was to attract highly qualified, academically trained faculty to run the emergency department. The only way to do that was to provide the highly trained academic faculty with a program that fosters their interests. Thus, the need for a training program became self-evident once the decision was made to try and improve the care of the patients," Dr. Shipley says.

The academic program in emergency medicine is only part of the hospital's plan for improving emergency care. The plan also includes a $3 million renovation to the emergency room, started in 1995, and creation in June 1995 of an urgent care center staffed by emergency medicine physicians who treat patients with less urgent medical needs after they are triaged in the emergency room.

There has always been an interest in emergency medicine on the part of P&S students, Dr. Shipley explains. Despite the lack of a P&S emergency medicine department, six members of the Class of 1995 entered emergency medicine residencies.

What are the qualities of a top emergency medicine physician? "In any order: a thick skin, a high level of confidence in your own diagnostic and therapeutic skills, and a very healthy dose of compassion," Dr. Shipley says. "Thick skin is necessary because the ER is a very stressful environment. The patients and their families have many demands, some of which can be met and some of which cannot. The level of illness is always very high. No matter how good a physician you are, no matter how smart you are, there are going to be bad days. There are going to be days when people have bad outcomes or die, and you need to be able to cope with that stress.

"Your diagnostic and therapeutic skills have to be as sharp as possible because we're always dealing with what I refer to as 'the information gap,'" says Dr. Shipley. "We don't know our patients; we've never seen them before, most of the time, and we'll never see them again. They don't have old records. I don't have their old X-rays, EKGs, or lab tests. In emergency department time, which is two to six hours, I need to make a decision about the health of this person and whether they need to be admitted or not. I can't keep a patient in the emergency department for 36 hours and order 17 tests. If it takes me that long, then they need to be in a hospital."

Finally, Dr. Shipley says, the ER physician needs compassion. "For the most part, at Presbyterian Hospital and in other similar urban emergency departments, you're seeing patients who have fallen through the cracks almost everywhere else," he explains. "They don't have private doctors, they've missed clinic appointments, they haven't been able to fill their prescriptions because they don't have the resources to do so. You and I can take care of simple medical problems at home, but it's hard to expect people to take care of themselves if they don't have a home."

Dr. Shipley completed residencies in emergency medicine and internal medicine at Bronx Municipal Hospital after graduating from Albert Einstein College of Medicine, but he predicts an emergency medicine resident's experience at P&S will be different from his own. "With the backing of a medical center like this one, we'll be able to do some things that other places can't. For instance, good academic level research is becoming an increasingly important aspect of emergency medicine. Most other specialties have a huge volume of academic research standing behind them, but emergency medicine is a new specialty and therefore doesn't have the same volume of academic research.

"Clinical research is being done in isolated places around the country, but basic science research is still lacking, and Columbia has a unique opportunity to take advantage of the research already here and the resources of the School of Public Health, the Department of Medical Informatics, and the Psychiatric Institute, for example. One of the ways our program will differ substantially from those of other schools will be the access we have to these extraordinary resources."

Also, as residents at a major tertiary referral center, the doctors in training will see transplant cases and illnesses that require major subspecialty intervention.

"We're going to try to have an undifferentiated approach, that is, with the exception of pediatric and psychiatric patients, we're not going to segregate the patients based on their complaints," Dr. Shipley says. "The resident will see whatever patient is the next one in. That's the beauty of the emergency department. We don't choose our patients. We see all comers. We view ourselves as the safety net for anybody and everybody who can't get care anywhere else, and we pride ourselves on giving the same high quality care to a VIP and to a person who has no home, no money, no insurance, and unfortunately was just robbed or mugged or hit by a car or found unconscious in the street. It's our job to make them better no matter who they are."

One of the other key points of the residency program will be an emphasis on progressive responsibility. First-year residents will not be expected to have the knowledge and skills of a seasoned emergency room veteran, but they will care for up to 10 patients at a time by the third year. "I make the analogy to the Chinese jugglers who spin the plates on little sticks in the circus," Dr. Shipley says. "They have to go back and touch each plate every couple of seconds. Otherwise, one will fall and break."

This constant activity, this constant demand upon time and training, will be a new facet of the graduate medical education Columbia-Presbyterian provides. "Emergency medicine residents may not log as many hours on the clock as other residents, but believe me, every second they're on duty in the emergency room is a high-stress second, and a 12-hour shift is a very stressful 12 hours. On top of that, they'll be getting involved in research projects. When you look at the whole package, you see that our program will contribute a lot to the university, the hospital, and the medical center as a whole. I hope that, with the recruitment of more academic faculty, more residency-trained board-certified emergency medicine physicians, we'll be able to meet our goal."

Doctor as Critic

A busy emergency medicine physician doesn't have much time or inclination for serious television criticism, but Dr. Neal Shipley is quick to share his thoughts on two medical dramas popular with students this season.
"Chicago Hope": Thumbs Down
"I don't like 'Chicago Hope,'" Dr. Shipley opines. "I think the physicians on the show are arrogant and they lack some of the compassion that good ER physicians need. The plots focus on extremely rare problems that only one physician on the entire planet is competent enough to fix, and he or she happens to be at Chicago Hope by some miracle of scheduling, every time. The emergency physician is a jack-of-all-trades, somebody who can take care of anybody and everybody. He hasn't studied one specific abnormality for 35 years so that he can treat one specific patient."

"Chicago Hope," a CBS drama that includes emergency room scenes

"ER," the NBC drama that depicts emergency medical care
"ER": Thumbs Up
"It's closer than any other show I've ever seen to what an emergency room is really like, except that they obviously have a lot of dramatic license and dramatic tension. It's rare that so many things happen within one hour in an emergency department. Still, if you take one hour of that show and expand it, you could see all those cases in a two- to three-day period, and sometimes in one 24-hour period." Dr. Shipley also notes that the program has a tendency to overemphasize romance. "The emergency room is not an environment that's really conducive to amour," he explains.
Dr. Shipley adds the caveat that his comments about "ER" may be slightly motivated by personal bias. "My wife thinks that I'm Dr. Greene reincarnated. With a little more hair."

copyright ©, Columbia-Presbyterian Medical Center

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