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Who’s afraid of emergency physicians?
  1. Daniele Orso
  1. Department of Emergency Medicine, Ospedale di Latisana (UD), A.A.S. 2 "Bassa Friulana - Isontina", Latisana, Italy
  1. Correspondence to Dr Daniele Orso, Department of Emergency Medicine, Ospedale di Latisana (UD), A.A.S. 2 "Bassa Friulana - Isontina", Latisana 33053, Italy; sd7782.do{at}gmail.com

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It is a bright summer day in 2014 and I am about to graduate in emergency medicine (EM). In front of me I see a radiant future for myself and for the discipline I chose to study 5 years earlier. I know that the road will not always be smooth, that I will have to overcome the scepticism of my future colleagues; but we are the first class of EM specialists in Italy, and finally, we have entered the contemporary era of medicine.

There are currently 28 European nations where EM is a primary specialty. The most recent is Spain, where the specialty started this year. In other countries, EM is a super-specialty that can be achieved at the end of one’s primary specialty path. In some European countries, the ‘struggle’ for the realisation of EM as autonomous specialty is still on. This is probably linked to the inhomogeneous economical levels of the different European states: many countries have come out of recent conflicts with neighbouring states, which have destroyed the social structure, such as some territories of the Balkan region, or some countries of the former Union of Soviet Socialist Republics (USSR).1 2

EM originated in the Anglo-Saxon countries and is relatively recent even in some countries such as South Africa. For many years the Franco-German model seems to have been imposed in most part of Europe: anaesthetists developed EM, especially in the prehospital setting. This approach is focused on resuscitation and on the execution of life-saving procedures.3 Diagnostic and other clinical skills required for the emergency physician within the hospitals (and the increase in population health needs) have led to the development of a new method of clinical reasoning. EM is a transversal specialty which deals not only with life threatening conditions (although these are a relevant component), but also with any pathology that requires prompt assessment. The emergency physician is used to reasoning in a unique way that is difficult to acquire through other medical disciplines: it is about estimating the probability of a series of differential diagnoses and at the same time treating the most likely or potentially lethal causes.

The first problem in establishing a new medical specialisation is how to properly train new specialists. The next problem is allowing the new specialists to apply their skills. In some countries, as in Italy, the health system seems not to take sufficient account of the resource of this ‘new’ medical discipline. In Italy the medical specialty of EM was established in 2009, based on the European curriculum developed by the European Society for EM.4 5 A dispute with the Italian Society of Anesthesia and Intensive Care delayed the beginning of EM as discipline (some thought this was because the anaesthetists believed the new specialty could steal some of their prerogatives).6 The controversy was brought to court where it was established that EM had a right to be founded in Italy, as it already exists in many other countries in the world.

In Italy, since before the institution of EM as a new specialty, there are 844 emergency departments (EDs) of which 513 first level and 331 second level; 76 operational centres for prehospital and retrieval medicine missions (eg, Emergency Medical Service (EMS) and Helicopter Emergency Medical Service (HEMS)).7 The first fully trained emergency physicians have been present since 2014: about 80 new specialists each year. This number is obviously insufficient to even partially cover the national demand. In the last 2 years, the Italian Ministry of Education has increased the number of residents in EM. In the last 4 years in Italy, about 300 specialists in EM have been registered, compared with about 2800 anaesthetists and 1600 general surgeons, required by the respective departments. Furthermore, we are still witnessing an incomplete recognition of the role of EM specialists. No preferential path for these specialists to work in the ED or EMS operational centres has been established. HEMS are almost closed to them throughout the national territory (in almost all cases this task is carried out by anaesthetists). Currently, most ED consultants are specialists in Internal Medicine or Surgery, who, however, spend a short time in the EDs before they can move into their departments. It seems that a bill of the current Italian government wants to allow general practitioners to obtain the status of specialists in EM, even if they have not studied this discipline.8 All these facts are making EM gradually less desirable for new graduates. We are losing more and more competent physicians who prefer to abandon their work in the ED rather than working in these conditions. For example, in many EDs airway management or procedural sedation cannot be performed by EM specialists. Moreover, for them there is no provision for an academic position.

The Italian situation shows that it is not enough to be able to obtain recognition of the primary specialty in EM. It is necessary to establish a real path that allows new specialists to do the work for which they have been trained and for which they still demonstrate their competence. EM has a unique systemic view of the patient and his health problems: it is concerned with making patient management safe; whether the patient should be hospitalised or has to be discharged. In this way, EM plays a key role in the health system: if, for some reason (eg, the lack of economic resources), the healthcare system goes into crisis, the ED is one of the first services to suffer the consequences. At the same time, EM is also one of the main available resources of the health system to get out of the crisis.

Four years later, am I still convinced of having a brilliant future in front of me? Surely, I trust that I could be a lever to develop the emergency health system in my country, using my determination and proficiency and that of my fellow specialists. I will get by with a little help from my friends…

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Footnotes

  • Contributors DO conceived the study and he drafted the work.

  • Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

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

  • Patient consent for publication Not required.