Each year, ACEP’s Council elects new leaders for the College at its meeting. The Council, which represents all 53 chapters, 39 sections of membership, the Association of Academic Chairs of Emergency Medicine, the Council of Emergency Medicine Residency Directors, the Emergency Medicine Residents’ Association (EMRA), and the Society for Academic Emergency Medicine, will elect the College’s President-Elect, Council Speaker and Vice Speaker, and four members to the ACEP Board of Directors when it meets in October. This month, we’ll meet the President-Elect candidates.
The following members are candidates for President-Elect. They responded to this prompt:
As 2019 is EMRA’s 45th anniversary, please define your thoughts and beliefs about residency training in emergency medicine, illustrated through your personal experiences.
Jon Mark Hirshon, MD, PhD, MPH, FACEP
Current Professional Positions: professor, department of emergency medicine and department of epidemiology and public health, University of Maryland School of Medicine, Baltimore; senior vice-chair of the University of Maryland, Baltimore Institutional Review Board
Internships and Residency: emergency medicine residency, Johns Hopkins Hospital, Johns Hopkins University, Baltimore; preventive medicine residency, Johns Hopkins Bloomberg School of Public Health
Medical Degree: MD, University of Southern California School of Medicine, Los Angeles (1990)
Response
Jon Mark Hirshon, MD, PhD, MPH, FACEP
It seems like just yesterday that I walked through the doors of Johns Hopkins Emergency Department to join eight fellow interns as we started our residency training and our careers in emergency medicine. Back then, we were still doing 24-hour shifts on the surgical side of the ED. As a newly minted doctor still trying to comfortably wear the recently-acquired mantle of physician responsibility and authority, it was both an awe-inspiring and somewhat intimidating experience. Despite the challenges of a new city, a new job, and a new role in life, I squared my shoulders and successfully stepped forward with the support of faculty, family, and friends. Three years later, after appropriate (and, at times, painful) guidance and training, I transitioned out of academia to the finishing school of community emergency practice in Baltimore for five years. Or, as one of my attendings said at the time, to go out and “get real-world experience” before teaching others.
While my emergency residency training was just one step in a long and successful career, it remains a critical and pivotal period in my professional development and personal growth. EM is a clinical, patient-focused specialty—our clinical expertise helps to define us professionally. We are, first and foremost, clinicians. For me, the personal satisfaction of treating patients is irreplaceable and remains one of the best parts of my EM practice. However, it was through residency training that I gained the knowledge and experience to be able to provide high-quality emergency care. As I tell my current residents, for me the two greatest clinical learning years were my internship year and my first year as an attending in the community. Without the outstanding training I received in residency, my knowledge and skills would not have enabled me to provide high-quality emergency care.
There is no question that residency training is the standard for developing outstanding emergency physicians. When EM first started 50 years ago, there were no EM training programs. I remain forever thankful for the heroic efforts of our founding leaders in developing our wonderful specialty. However, at 50 years, we are a fully developed member of the house of medicine. Our current and future value is based on quality residency training in combination with increasing our knowledge base through research. As ACEP Vice President, I have had the real pleasure of being the ACEP Board liaison to the EMRA Board of Directors this past year. It has been a natural fit for me after more than two decades of being a faculty member at outstanding residency programs. While patient care remains an important and valued aspect of my professional life, equally important is my role as teacher and mentor to young clinicians and researchers. Helping to guide young physicians as they develop into self-confident, excellent physicians remains one of the best aspects of my career, and I feel honored to be able to continue to serve in this role.
Still, there are a number of concerning issues and current trends related to EM residency training. These include: 1) the rapid expansion of residency programs (from 153 in 2010 to more than 240 today) and how this will impact the educational environment, future workforce needs, and young physicians’ employment opportunities; 2) the ongoing challenges of integrating osteopathic and allopathic training programs and how this impacts current and future trainees; and 3) the Accreditation Council for Graduate Medical Education’s removal of protected time for EM faculty with the new common program requirements despite strong and united opposition from ACEP, EMRA, and other EM organizations. We must remain vigilant and dedicated to ensuring that our emergency physicians in training are receiving outstanding education and guidance within appropriately designed and supported educational environments.
At 45 years, EMRA remains a youthful, vibrant, trailblazing organization led by incredibly talented and thoughtful physicians. Their energy, drive, and creativity are exemplary, and I continue to learn much from them as they help develop the future of our specialty. Still, we need to carefully navigate between the shoals on our left of increasing bureaucratic demands and physician burnout and the raging storm to our right of economic pressures to decrease health care costs and the financial burdens on patients (as exemplified by the current congressional battles related to out-of-network billing and inadequate insurance coverage). As stated in my speech in front of the Council last year, it is imperative that we work together to: 1) improve our lives at the bedside in the ED; 2) ensure we can deliver the highest-quality emergency care possible; and 3) make sure that we receive fair compensation for the care we deliver. This will be accomplished in the future through graduates of high-quality EM residency training programs and the exceptional, committed resident leaders in EMRA.
Mark Rosenberg, DO, MBA, FACEP
Mark Rosenberg, DO, MBA, FACEP
Current Professional Positions: chairman of emergency medicine, chief innovation officer, and associate professor of emergency medicine, St Joseph’s Health, Paterson, New Jersey
Internships and Residency: emergency medicine internship and residency, Metropolitan Hospital, Philadelphia
Medical Degree: DO, Philadelphia College of Osteopathic Medicine (1978)
Response
EM residencies have become the standard for training and education, and maintaining these rigorous standards and curriculum is critical. Across our country, there are more than 240 residency programs and more than 2,200 EM residency slots. I value residency training so much that in 2004 I started an EM residency at St. Joseph’s University Medical Center, which is now affiliated with New York Medical College. The program is accredited by the Accreditation Council for Graduate Medical Education and has 24 residents. We have 12 core faculty and systemwide support.
I think it is critically important for each of us to protect and defend our emergency residency programs. Residency training is fundamentally important as the cornerstone of our specialty of emergency medicine. Because of my experience in the early years of the specialty, I have always been a staunch advocate of residency programs, supporting EM residencies throughout my career and having developed an EM residency program at my current practice.
Without belaboring the point, as we all know the history of EM, I believe a few words focusing on the early growth of our specialty are relevant to this question as it profoundly influenced my professional life and commitment to residency programs. As Brian Zink said, “Unlike the residents of today, those physicians who pursued emergency medicine residency training in the early 1970s faced an uncertain future. They had no opportunity to be certified by a specialty board and had no guarantee their chosen field would persist. They were pioneers and mavericks in spirit and action. And despite the severe lack of teachers, curricula, and resources, they managed to learn and become leaders by relying on each other.”1 But some of the very docs who fought for EM to be a specialty were the same docs who were at risk of losing everything due to their lack of standardized training. I have had the distinct privilege of participating in those tumultuous years of our specialty.
My own residency experience is one I can never forget as it influenced my career decisions over years of clinical practice. In 1978, I began my internship at Metropolitan Hospital in Philadelphia just as a new emergency department medical director joined the staff. He was residency-trained in EM from one of the few residency programs in the country. The ED was under the department of surgery, and one of the core EM textbooks at the time was written by surgeons! After completing my internship, I started working in the ED with hands-on training from the medical director/program director. We had a shared vision to get the training accredited as a residency program, and I would be the first graduating resident. But things did not work out as I had planned. The program never became accredited, and my program director decided to leave Philadelphia and go back to Florida where he trained.
I continued working as an emergency physician, and in 1980, I joined the EM faculty at Philadelphia College of Osteopathic Medicine. This was the first osteopathic emergency medicine residency program that started in 1979. All the faculty were from other specialties, not EM, but all were dedicated to making the specialty what it is today.
To address the situation of those EM physicians who did not have a residency, ACEP and the American Board of Emergency Medicine (ABEM) developed a practice pathway, which closed in 1988. For a limited time, this group of physicians had the opportunity to meet the requirements established by ABEM, making them eligible to sit for the boards. That is how physicians such as myself became board-certified in EM. I am proud to say I am triple boarded, with EM boards from ABEM and the American Osteopathic Board of Emergency Medicine, and palliative medicine boards through ABEM.
The practice pathway was a window of opportunity that recognized the significant contribution of those physicians prior to residencies and also recognized the significant growth of our specialty. As EM grew, so did the need for validation of practice standards and board certification as in other specialties. Today, a practice pathway is no longer relevant. I strongly believe that EM residency training programs are the only pathway to EM practice and board certification.
We are the specialty of EM with a mandate of 24/7/365 in every ED across this country. Because of our irrevocable commitment to EM residencies, we continue to achieve this mandate every day.
Reference
- Zink BJ. A brief history of emergency medicine residency training. EM Resident. Feb./March 2005. Accessed June 17, 2019.
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