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Brief history of the specialty of emergency medicine
  1. David John Williams
  1. Correspondence to Dr David John Williams, Royal College of Emergency Medicine, London SW200DG, UK; djwilliams01{at}yahoo.co.uk

Abstract

This is a brief overview of the development of the specialty of Emergency Medicine from small beginnings fifty years ago. It describes how the specialty evolved simultaneously in the UK and the USA and later in Australasia and Europe.

  • emergency departments

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‘When I use a word’, said Humpty Dumpty (figure 1), ‘it means exactly what I choose it to mean, neither more nor less.’ ‘The question is’, said Alice, ‘whether you can make words mean different things.’ ‘The question is’, said Humpty Dumpty, ‘which is to be the master – that’s all.’

In this particular context, the word to be questioned is not, as so often, the emergency of medicine, but ‘specialty’ which can refer in general to a type of work that someone does most or does best or knows in depth. In medical terminology, however, specialty has the more specific meaning of a clinical discipline with four essential features: a unique field of action, a defined body of knowledge, an active research programme and a rigorous training programme. Few would deny that emergency medicine is now an established specialty which finds place with other major medical disciplines, but the battle to achieve that status has been long and arduous and it can be difficult to determine exactly when emergency medicine was accepted as an independent field of practice. Nonetheless, there is no doubt that it is now recognised as a primary specialty in the UK and many parts of Europe, in the USA and Canada, in Australia and New Zealand, in South Africa and in some Asian countries. It is said that history is simply the biography of the mind of man and that much of the most significant history is to be found written in the lives of great men and women. This is surely true for the history of emergency medicine because the foundations of the specialty may reasonably be ascribed to several remarkable pioneers.

In the beginning: in the UK

Emergency Medicine doctors should not be trained, they should be found. (A British orthopaedic surgeon)

In 1951, Maurice Ellis (figure 2) was appointed to be the consultant in charge of the ‘Casualty Department’, as the ED was then known, at the main hospital in Leeds. This was the first appointment of its kind, and such was the opposition of colleagues in other medical disciplines that he was not initially invited to attend meetings of the Hospital Medical Committee. His response was to transform the standards of training in his department and thereby to transform the department’s reputation in the hospital. By the time of his retirement in 1969, Maurice Ellis was still the only consultant in his unrecognised field of practice but he had by then recruited a small group of colleagues who worked together to improve the standards of care provided in EDs and to increase knowledge and awareness of emergency care in the hospital service. This group first met in London on 12 October 1967 and agreed as their first agenda item that they should henceforward be known as the Casualty Surgeons Association.

In the beginning: in the USA

Emergency medicine is not a specialty, it’s a location.(An American physician)

In 1966, a former general practitioner, John Wiegenstein (figure 3), was appointed to be a full-time doctor in the ED of the St Lawrence Hospital in Michigan. He soon discovered that there was no national association for emergency doctors in the USA, and he identified several colleagues who met together during the afternoon of 1 August 1968 and decided, perhaps rather presumptuously, to call themselves the American College of Emergency Physicians (ACEP). Wiegenstein was elected as the first chairman, and just 4 years later the college had >3000 members and was developing a mission to achieve specialty recognition for emergency medicine.

In the beginning: in Europe

Emergency medicine is pointing in a very wrong direction which is bound to fail. (A European anaesthetist)

In 1990, the Casualty Surgeons Association (soon to become the British Association for Accident and Emergency Medicine) held its annual scientific meeting in Manchester. One of the invited speakers was Herman Delooz (figure 4), Professor of Anaesthesiology and Intensive Care Medicine in the University of Leuven in Belgium. His title was ‘Emergency Medicine—a European perspective’, and he suggested that an association should be formed to promote the development of emergency medicine across Europe. Four years later he became the first president of the European Society for Emergency Medicine. At that time, emergency medicine was recognised as a primary specialty in only two European countries, the UK and Ireland. There has been slow but steady progress since then, but the opposition of many established medical specialists, particularly anaesthetists and surgeons, has mirrored the problems encountered in earlier years in the UK, the USA and elsewhere.

And then: in the UK

These early visionaries established associations with like-minded colleagues working in EDs, but they did not initially have expectation that their field of practice could become an independent specialty and it took many years of endeavour, medical political lobbying and frequent frustration before this was to be achieved. In 1972, following many national enquiries in the preceding two decades, the UK Department of Health created 32 experimental posts for consultants in charge of EDs but without a specialty being specified. Further appointments followed, but the supply of suitable candidates was very limited and there soon followed a moratorium on additional consultant posts. Nonetheless, the need for a specific training programme in emergency medicine had been recognised, and it was agreed that a committee should be established to develop a curriculum and criteria for the recognition of training posts in this new specialty. The first Senior Registrars were appointed in 1977, and there was a gradual increase in their number when the moratorium was later lifted.

However, the EDs were still mostly staffed by very junior doctors and by a large number of overseas graduates who had difficulty in obtaining posts elsewhere in the hospital service. The persisting shortage of these junior doctors (Senior House Officers) led to innovative practices such as the employment of nurse practitioners and experienced family doctors to see less serious cases, but these had limited effect in controlling the pressure of work. As recently as the mid-1990s, the Department of Health convened an urgent meeting to seek to resolve this continuing crisis of junior medical staffing but it has since been displaced by even greater issues. These include a very significant rise in the number of patients attending, an ageing population, international migration and acts of terrorism, issues mirrored elsewhere in the world.

The first specialty qualification in emergency medicine was offered by the Royal College of Surgeons of Edinburgh in 1986, and this was a fellowship which gave entitlement to entry into higher specialist training. Thus, three of the essential features for a new clinical discipline—a unique field of action, a defined body of knowledge and a rigorous training programme—were now in place, and there soon followed the creation of an Emergency Medicine Research Society and the appointment of the first Professor of Emergency Medicine. The foundation stones for the new specialty had been laid.

And then: elsewhere

Successful development of the specialty was taking place elsewhere in the world but most especially in the USA, Canada, Australia and New Zealand and, in more recent years, in European countries. The USA, in particular, followed a very similar path to the UK. ACEP leaders initially hoped to gain approval for an independent Board of Emergency Medicine but had to accept the compromise of a board conjoined with many other medical disciplines, and it was not until 1989, 10 years later, that they achieved primary board status.

Emergency medicine pioneers in Canada formed an Association of Emergency Physicians in 1977, and 3 years later emergency medicine was recognised as a free-standing specialty by the Royal College of Physicians and Surgeons of Canada. The Australasian Society for Emergency Medicine was established in 1981, and the Australasian College for Emergency Medicine was incorporated in 1984. It is only in this twenty-first century that countries on mainland Europe have made similar progress but there are now >17 where emergency medicine is recognised as a primary specialty with a common curriculum, a 5-year training programme and an examination to recognise the completion of training.

And later in the UK

In 1988, senior members of the Casualty Surgeons Association met to consider the possible establishment of a faculty, an academic body which, in the UK, may be the forerunner of an independent college. Informal meetings were held with the presidents of the Royal Colleges of Physicians and Surgeons, but the proposal was met with muted enthusiasm and, indeed, with considerable opposition to what was seen as the potential fragmentation of medicine. Nonetheless, they persisted in their endeavour and a change in the organisation of higher specialist surgical qualifications gave them their opportunity. The three Royal Surgical Colleges of England, Edinburgh and Glasgow proposed that a new faculty should be developed under their sole aegis, but the Royal College of Physicians of London, with a different examination structure and still opposed in principle, said that they would not wish to be excluded if a faculty was to be established.

Thus it was that in November 1993 the Faculty of Accident and Emergency Medicine was inaugurated at a meeting addressed by the presidents of the six supporting medical Royal Colleges. Three years later was held the first diet of the fellowship examination which recognises the successful completion of specialist training. Negotiations were then started to merge the association and the faculty into a single organisation to be known as the College of Emergency Medicine, and several years later, in 2015, the Queen granted the college its Royal Charter. True independence had at last been gained and emergency medicine became one of only 11 specialties in the UK to be represented by a medical Royal College.

The agenda of a meeting of the Casualty Surgeons Association in 1973 included items relating to academic posts to promote research, a curriculum-based examination, a higher training programme and the creation of a Faculty of Emergency Medicine. It was 20 years before the last of these ambitions was to be achieved, but the earlier agenda items had identified the essential features of a specialty. Humpty Dumpty would doubtless have agreed that that was exactly what he chose the word to mean, neither more nor less.

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Footnotes

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.