Anaesthesiologists in emergency medicine: the desirable manpower

Doctors, healthcare professionals, and regional and national administrators have realized the importance of early diagnosis, treatment and management of patients with acute and urgent, life-threatening, signs and symptoms following a variety of injuries, disorders and disease in recent years in Europe. An interesting debate has been going on between various European stakeholders and in various contexts for some time about how to offer high-quality emergency medicine services to as many patients as possible in any place and at any time in Europe. Moreover, the question has arisen of whether the installation of a primary specialty in emergency medicine would be beneficial for many patients, in many places all over Europe. These discussions are confusing owing to many misconceptions, false assumptions and inconsistent definitions. Therefore, it is important to create some order and analyse different aspects of this matter, starting with the definition of emergency medicine. For emergency medicine, a number of definitions have been formulated. The International Federation for Emergency Medicine defined emergency medicine as a ‘field of practice’ dealing with ‘acute and urgent aspects of illness’ (http://www.ifem.cc/about/about.htm), whereas, more recently, the European Society for Emergency Medicine (EuSEM) has defined emergency medicine as a ‘specialty’ dealing with ‘urgent and emergency aspects of illness’ (http://www.eusem.org/Pages/About_EuSEM/Policy_Statements/Policy_Statements.html). Confusion remains because of an overlap in the meanings of ‘emergency’, ‘urgency’ and ‘acute’. It is of note that the meaning of urgent (‘endangering vital functions and/or life threatening’) is recognized by all parties to be an integral concept in emergency medicine. The risk of a too wide or vague emergency medicine definition is that emergency situations, which can abruptly deteriorate and require immediate (minutes) intervention to avoid death or disability and disease areas of medicine where only initial care is needed for the acutely ill patient are then contained under the same umbrella and, more specifically, in the same medical organization. This leads to inefficiency and an unnecessary sharp rise in costs. In the worst scenario, patients with no emergency or acute illness at all may be forced to refer to the emergency system only because of a deficiency in the healthcare system. The consequences are an unacceptable overcrowded system at risk of failure or a bad outcome. We cannot forget what Peter Safar wrote, ‘the most sophisticated intensive care often becomes unnecessarily expensive terminal care when the pre-ICU system fails’. In European countries, emergency medicine education and training is well established but varies widely between individual EU Member States. At undergraduate level, emergency medicine is a mandatory medical school subject, generally held by internists and anaesthesiologists, in 16 countries. At postgraduate level, emergency care providers receive specialist education and training in programmes offered by universities, government agencies, private training institutions or as part of continuing professional education. In many cases, physicians come from different specialities, mostly anaesthesia, internal medicine and surgery. It is a point of concern that the primary speciality in emergency medicine is one of the youngest medical specialties. It began in the United States in the early 1960s, where it became a defined specialty in the 1980s. It has to be pointed out that, in the United States, emergency medicine essentially is acute medicine for the 60 million Americans without medical insurance. The United Kingdom was the first European country to institute a speciality examination in 1983. Today, in Europe, the primary specialty in emergency medicine is listed in the ‘Doctors’ Directive’ 2006/100/EC in nine EU Member States out of 27. Although not enlisted in the directive, in Belgium, a primary specialty in emergency medicine is now active and coexists with the previous education in emergency medicine consisting of a primary specialty in anaesthesia, internal medicine or other followed by a superspeciality training. In Italy, a primary specialty in emergency medicine, abruptly created by law, has been very recently instituted. The wide variations in emergency medicine training observed in Europe may be due to the difficulty in considering emergency medicine as a discipline or as a competence that all doctors should have. Anaesthesiology is a medical specialization with defined areas of expertise including perioperative anaesthesia care, intensive care medicine and resuscitation, emergency medicine and pain medicine. The postoperative period, critical care and prehospital and in-hospital management of emergency situations are so strongly associated with the skills and expertise of anaesthesiologists in their work in the operating room that anaesthesiological expertise in these areas has been recognized in many countries as an integral part of the specialty in anaesthesiology. Common principles include stabilization/normalization of vital physiological parameters, provision of adequate sedation and analgesia and maintenance of an appropriate fluid balance. Anaesthesiologists should, therefore, be considered ‘clinical generalist physician specialists', not simply specialists of organs or disorders. Today, anaesthesiologists are members if not leaders of emergency teams, being recommended as the best experts to be involved for extremely difficult emergencies at the same time coordinating activities of other (‘organ-’) specialists as anaesthesiologists do in the operating theatre environment. Anaesthesiologists are involved in the teaching and training of emergency medicine, as well as in research in the field of emergency medicine in all European countries. Anaesthesiologists are thus a desirable manpower in emergency medicine. It is evident that with their the background, skills and daily clinical and academic activities anaesthesiologists have played a key role in the development of emergency medicine and must keep on playing a crucial role in the future. However, it is important to underline that anaesthesiologists are experts in dealing with life-threatening emergency conditions and not with acute medicine. Acute medicine is an integral part of every medical specialization. To reenforce the skills and knowledge in medical life-threatening emergencies and offer a well tolerated and high-quality care, the European Union of Medical Specialists (UEMS) section and board of anaesthesiologists developed a core curriculum in emergency medicine that was suggested to be integrated in the specialty of anaesthesiology [1]. For certain, the curriculum was not developed to promote exclusivity in the emergency medicine field, as feared [2], but not to be tout court excluded [3]. Progress in pursuing uniformity of higher education within the EU has been promoted in recent years. With the aim of harmonizing higher training in emergency medicine, the EuSEM proposed to the UEMS that a Multidisciplinary Joint Committee on Emergency Medicine (MDJC-EM) should be instituted. The main task of the MDJC-EM has been the development of the European Curriculum for Emergency Medicine, which, drafted by exponents of the EuSEM, has been recently approved by the MDJC-EM and endorsed by UEMS. The aim of the European Core Curriculum was to create a platform for a homogeneous and uniform training of emergency medicine, a useful tool both for countries in which emergency medicine exists as a primary specialty and for those in which it does not. Somewhat in contrast to the former proposal, the EuSEM has also been a strong supporter of the installation of a primary specialty in emergency medicine (http://www.ifem.cc/about/about.htm). The UEMS section and board of anaesthesiology is convinced that the quality of medical care in Europe is not necessarily served by applying for and installing more and more medical specialties in general. The increase in medical knowledge in recent decades and the associated technical progress has resulted in an increase in specialization and in an increase in the number of medical specialities, which in some countries has caused more confusion rather than being an essential contribution to the improvement of medical care. The increase in medical specialties and subspecialties in some countries has in fact caused unwanted overlap and discussions on the responsibilities and domain of the (subspecialities or supraspecialities) specialities, has erected borders and has limited communication between doctors and healthcare providers. Regarding emergency medicine, the pros of a primary specialty in emergency medicine can be identified in the recognizable entity of an emergency department, curriculum development, improvement in efficiency of low-risk emergencies in emergency departments and identification of quality standards. On the contrary, the cons are existing healthcare systems and structures, realistic and unacceptable delay in high-risk emergencies, risk of isolation of emergency medicine from other medical specializations, extra bureaucracy (and costs?). Moreover, in many countries where there is not a history or tradition of emergency physicians, the institution of a primary specialty in emergency medicine may only create a physician able to do a little of everything: a modern version of a general practitioner. It is obvious that any achievement in medicine can not be performed by individuals or by individual specializations. Today emphasis should be placed on quality and safety, on decreasing resources and on increasing demand to ‘do more with less’. It is time for mutual respect between medical specializations and the recognition that for certain areas intensive communication and a multidisciplinary approach with respect for each other's specific expertise will be more beneficial for the quality of care than endlessly expanding the number of specializations and kingdoms. Accordingly, for emergency medicine, it would be feasible to adopt a multidisciplinary approach by specialists with special competencies. This is not a question of exclusivity for any medical specialty whatsoever. Although not quite comparable owing to the differences in history for emergency medicine, as for intensive care medicine, wide variations exist in the definition and organization of care, in the competence of doctors, in financial resources, in demand, in availability and in quality of care. This diversity has considerably increased after the expansion of the European Union in the last few years. The best solution for country A will not lead to the best results in country B. Therefore, harmonization of emergency medicine quality of care throughout Europe is a challenge. And this is what the Multidisciplinary Joint Committee of Emergency Medicine should aim for. What is now important is to reach agreement on the widely varying current definitions and agreement on the competencies that are required to provide high-quality medical care in this field. The European core curriculum on emergency medicine developed by the MDJC on emergency medicine is an important step, and a useful tool, but there is still a long way to go to achieve this essential harmonization. We should recognize that there are different routes to the practice of emergency medicine throughout Europe. A primary specialty in emergency medicine can be a reasonable solution in some countries, but in many others, a high-quality education in emergency medicine can also be achieved by facilitating the acquisition of harmonized common competencies in emergency medicine by trainees from a wide variety of primary speciality training programmes. This may also have the added benefit of optimizing the staffing of emergency departments. Only after agreement on definitions, clear fields of action, competencies and training has been achieved will national medical councils decide on whether the installation of a separate primary medical speciality in emergency medicine may contribute to improve emergency medical care, taking national history, current situation and organization of care into consideration.