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Subspecialisation in emergency medicine: A specialty at the crossroads

2016; Wiley; Volume: 28; Issue: 4 Linguagem: Inglês

10.1111/1742-6723.12629

1742-6731

Michael JR Edmonds, Suzanne Hamilton, Lisa Brichko,

Cardiac, Anesthesia and Surgical Outcomes

Emergency medicine (EM) is the art of caring for undifferentiated, unscheduled and unprepared patients. The nature of this practice attracts doctors with open minds, broad skill sets and generalist experience. However, as healthcare demands evolve, there is now growing consideration of the role of subspecialisation in Australasian EM among trainees and FACEMs. Emergency medicine has recent origins, recognised only over the past 40 years as a distinct field, and gaining principal specialty recognition in Australia in 1993 and New Zealand in 1995.1 Prior to this, EM evolved as a subspecialty of medicine and surgery.2 Initially thought superfluous, specialisation in EM fills an important void in the healthcare system. Now, no other specialty can manage the same vast array of patients, from social crises to post-partum haemorrhage to paediatric multi-trauma. Currently, ACEM has no subspecialty pathways or policy, although this is recognised as a 'future challenge'.3 Arguably, the subspecialisation of other facets of medicine, such as internal medicine and surgery, has lead to fragmented care that struggles to meet the needs of the undifferentiated patient or one with multi-system disease – a significant proportion of ED patients.4, 5 A case example may be the unstable diabetic patient with acute coronary syndrome who is on regular haemodialysis – a tragically unfortunate patient who has no clear 'home team' in the fragmented world of subspecialised medicine. Another may be the patient suffering severe multi-trauma requiring damage control surgery extending from pelvic to thoracic cavities, where the on-call surgeon generally operates in an unrelated subspecialised field. However, subspecialisation helps drive advances in knowledge, patient outcomes and technology. The development of new techniques or equipment would struggle to progress if subspecialists did not concentrate on a narrow field of practice. The proven benefit of stroke specialist team care and primary reperfusion therapy for ST-elevation myocardial infarction are easy examples. The evolution of now-established specialties, including EM itself, provides further examples of benefits of subspecialising. The College for Intensive Care Medicine of Australia and New Zealand (CICM) evolved from being separate subspecialties of medicine and anaesthesia (itself a 'subspecialty' within the college of surgeons until 1992) to a recognised joint faculty of the colleges in 2001. It wasn't until 2010 that the newly formed CICM took over responsibility for training and certification of intensive care specialists.6 Where EM represents the hospital-based generalist physician, general practice has been the only community-based generalist profession. However, over the past decade, The Royal Australian College of General Practitioners (RACGP) has recognised the diversity of subspecialist practice in general practice. Since 2008, RACGP have endorsed 20 networks under the Faculty of Special Interests, including addiction medicine, aged care, cancer, paediatrics, diabetes, medical education, obesity, pain and refugee medicine.7 This has been a controversial shift, although it is argued that this has allowed better patient care, acquisition of specialist equipment and improved income while reducing the cost of specialist care.8, 9 With trainees and FACEMs increasingly entertaining a special interest in addition to general EM, some believe that subspecialisation may become the new norm.10 However, ACEM has not defined subspecialisation in the setting of Australasian EM, nor are there currently accredited, EM-specific pathways. Trainees may pursue dual fellowships, most commonly in paediatric EM, intensive care or anaesthetics, or any number of postgraduate certificates, diplomas or degrees in fields such as toxicology, ultrasound, education, simulation or pre-hospital and retrieval medicine. In large, these extra qualifications are not EM-specific, and have requirements in excess of those relevant to EM practice. The progression from special interest into a formal subspecialty depends on a critical mass of physicians who can define a unique clinical role and drive the development of supporting education and research programmes.11 To do so, the field has to represent a unique body of knowledge and practice that cannot be fully incorporated into the parent specialty, driven by patient need (Table 1).11, 12 Arguably, a subspecialist may devote much of their attention and energy to this field of practice at the expense of generalist practice. The implementation of subspecialisation must consider the benefits, such as defining a clear standard for an emerging practice and the advancement of knowledge in the field, against potential downsides, such as the cost of creating and maintaining certification and fragmentation of care. A failure in this process and the promulgation of subspecialties without adequate justification may not achieve any benefit.12 The implementation and consequences of EM subspecialisation internationally are explored further in the article by Maitra et al. in this issue.13 Emergency medicine in the UK has two defined pathways for subspecialisation within the Royal College of Emergency Medicine: paediatric and pre-hospital EM. Both have formal recruitment processes, defined programmes (12 months for each) and strict assessment criteria. At present, all doctors in the UK are registered with the General Medical Council (GMC) and work through training programmes to achieve a Certificate of Completion of Training (CCT) in their chosen discipline – analogous to FACEM qualification. For trainees who successfully complete a subspecialisation programme, their CCT acknowledges this additional accreditation on their GMC registration. Emergency medicine in the USA recognised subspecialty boards in 2007. The American College of Emergency Physicians currently recognises subspecialist certifications formalised through umbrella organisations similar to the Medical Board of Australia and Australian Medical Council. Currently, EM subspecialties include critical care, pre-hospital EM, hospital and palliative medicine, internal medicine, toxicology, paediatric EM, sports medicine and undersea and hyperbaric medicine.14 Ultrasound qualifications are the domain of well-established, EM-specific training with reasoning that 'any non-emergency medicine external certification process would impede the use of this critical clinical skill and adversely affect patient care'.15 Despite early recognition, only 4.3% of American Board of Emergency Medicine diplomats hold a subspecialty certificate.16 A broad range of EM special skills are represented in Australasia, suggesting some enthusiasm among FACEMs and trainees to subspecialise. Accredited special skills posts for ACEM trainees include rotations in addiction medicine, forensic medicine, education, geriatric medicine, medical administration, pre-hospital and retrieval medicine, toxicology and ultrasound.17 Some of these may be considered as candidates for development as formal EM subspecialties. Subspecialisation may allow more advanced treatments of specific patient groups, in a system where EM physicians may not all provide the same range of services.2 Indeed, as care becomes regionalised to specialist hospitals, such as for trauma, paediatrics, stroke or other specialist care, EM physicians in these centres will similarly need to become more specialised.18 For the individual, a subspecialised field of practice may be more manageable to maintain knowledge and skills and may promote job satisfaction and longevity. Subspecialists would play a role in educating and maintaining skills among otherwise generalist trainees and FACEMs,19 arguably raising the standard across the department in their discipline. Additional qualifications may assist trainees in securing employment,20 whereas hospitals and administrators may seek formal assurance of the knowledge and skills a physician brings to their institution.12 The core of EM practice revolves around undifferentiated conditions, and the sheer range of pathology demands that the treating EM physician maintain a high standard of generalist knowledge and skills. It may not be possible for subspecialists to limit their practice to a subset of these patients, mandating maintenance of both subspecialist and generalist skills. Some suggest this remains beneficial through preventing erosion of core general EM capabilities.19 Subspecialists working in an environment with limited exposure to general EM patients, such as in a dedicated paediatric department or the pre-hospital arena, may find their generalist skills more difficult to maintain. However, an increased reliance on subspecialisation may reduce the scope, skills and reputation of the 'generalist' physician.11, 12 Examples might include the deterioration of skills in ultrasound or toxicology as these become distinct from general EM. Departments may require a larger workforce to ensure the same breadth of EM is covered, although arguably with greater depth of knowledge across subspecialist fields. In addition to increased cost, workforce may suffer from increased subspecialisation, with doctors unable to change specialties or unwilling to move to geographic areas in need.21 Physicians may find that the extra investment in subspecialisation may not be appropriately renumerated.16 It is the broad nature of EM and the ability to treat all comers that attracts many trainees; EM is the last bastion of hospital-based generalist specialties. With increasing subspecialisation of in-hospital services, it is all the more incumbent on EM physicians to be the guardians of generalist knowledge. Indeed, EM may already be too specialised with a narrow focus on emergency patients and loss of rest-of-hospital perspective, in which case, 're-generalising' EM trainees and practice may be beneficial. The evolution, then, to a subspecialised profession must be progressed with great consideration. Lessons from international experience must be applied to the Australasian healthcare system. The chosen disciplines developed as formal subspecialisation pathways must meet criteria, with demonstrable benefits to patients, society and the practice of EM. Subspecialties must augment EM knowledge without diminishing the core practice. Our future path must consider how EM physicians can meet societal healthcare needs and continue to be 'everything to everyone'. MJRE, SH and LB are section editors for Emergency Medicine Australasia.