The field of emergency medicine evolved out of the necessity of caring for a rapidly growing population of patients seeking immediate and unscheduled medical care for emergency conditions. By 1960, it became clear that the number of emergency department visits was rising across the United States. Physicians lacked the necessary emergency medical skills to properly care for these patients and were frustrated by the growing demand. In response, the Pontiac and Alexandria Plans were enacted in 1961. At Pontiac General Hospital (MI), 23 community physicians began working part-time to staff their emergency department around-the-clock. In Alexandria (VA), another group of physicians left their private patients to become full-time emergency physicians.
Though physicians began devoting varying degrees of their practices to emergency medicine, there was still a need for specialized training. In 1967, the American Medical Association (AMA) established a committee on emergency medicine, and in 1968 John Wiegenstein and seven colleagues founded the American College of Emergency Physicians (ACEP). ACEP's first Scientific Assembly was held in 1969.
In 1970, the University Association for Emergency Medical Services (UAEMS) was formed for scientific and educational purposes by medical school faculty practicing emergency medicine. Prior to its establishment, medical students were already choosing emergency medicine as a career path. The first university emergency medicine residency arose at the University of Cincinnati in 1970 where Bruce Janiak became the initial resident. Other sentinel university programs include those at Los Angeles County/University of Southern California Medical Center (1971), the Medical College of Pennsylvania (1972), the University of Chicago (1972), and the University of Louisville (1973). R.R. Hannas established the first community hospital emergency medicine residency in 1973 at Evanston Hospital (IL). The Emergency Medicine Residents Association (EMRA) was formed in 1974 to unite the initial residents in our field.
The road to specialty recognition was particularly challenging. A provisional Section Council in emergency medicine was established in the AMA House of Delegates in 1973 and became permanent in 1975. Also in 1975, the Liaison Residency Endorsement Committee, the forerunner to the Residency Review Committee for Emergency Medicine (RRC/EM) was created. In 1976, the American Board of Emergency Medicine (ABEM) was incorporated and the American Board of Medical Specialties (ABMS) finally recognized emergency medicine in 1979. Unlike the boards of other fields, ABEM was initially required to be conjoint with other medical specialties represented.
The emergence of osteopaths in the field occurred in 1975 when the American College of Osteopathic Emergency Physicians (ACOEP) became an affiliate college of the American Osteopathic Association (AOA). The first osteopathic emergency medicine residency began in 1979 and Gerald Reynolds became the initial resident at the Philadelphia College of Osteopathic Emergency Medicine. In July 1978, the American Osteopathic Board of Emergency Medicine (AOBEM) was established as an affiliate specialty board of the AOA. ACOEP's first Scientific Assembly was held in 1978.
ABEM administered the first emergency medicine board examination in 1980 and AOBEM followed suit in 1981. In 1982, the Accreditation Council for Graduate Medical Education (ACGME) approved special requirements for emergency medicine residency training programs.
In 1988, after a well-publicized 10-year grace period, ABEM eliminated the practice track and began to require emergency medicine residency training to qualify for the ABEM certification exam. Shortly afterward, a one-time exception was granted to about 100 academic emergency physicians boarded in internal medicine. The practice track for AOBEM certification is also effectively closed at this point since it is restricted to those who began emergency medicine practice prior to 1986.
The organization, Board of Certification in Emergency Medicine (BCEM), was formed in 1987 to create a loophole for those choosing to practice emergency medicine without formal training. That same year, BCEM certified the first group of physicians ineligible for ABEM or AOBEM certification.
In 1989, emergency medicine became a primary board by ABMS. This recognition was dependent on, among other things, closing the ABEM practice track. Also in 1989, UAEMS and the Society for Teachers of Emergency Medicine (STEM) merged to become the Society for Academic Emergency Medicine (SAEM). The Council of Residency Directors (CORD) was formed later as a separate entity representing residency program directors and their assistants.
The 1990s brought turmoil to emergency medicine. In 1990, Gregory Daniel, a general surgeon practicing emergency medicine in Buffalo, New York, filed suit against ABEM and other individuals and institutions in academic emergency medicine. He and numerous co-plaintiffs from the non-academic community alleged that ABEM's closing of the practice track was the result of an illegal conspiracy to enhance the economic position of board-certified emergency physicians. In 1991, the Association of Emergency Physicians (AEP), formerly called the Association of Disenfranchised Emergency Physicians, was formed with the goal of reopening emergency medicine board certification for non-EM residency trained physicians. Dr. Daniel served on the AEP Board of Directors.
In 1992, under the alias "The Phoenix," James Keaney published The Rape of Emergency Medicine, which detailed corruption that negatively impacted patient care. He maintained that exploitation of emergency physicians was rampant. Many "leaders" in the field were siphoning significant profits through unfair business tactics and hiring unqualified emergency physicians willing to work for less pay. This wake-up call beckoned the formation of the American Academy of Emergency Medicine (AAEM).
AAEM was established in 1993 to promote fair and equitable practice environments necessary to allow emergency physicians to deliver the highest quality of patient care. Its first Scientific Assembly was held in 1994. AAEM initially defined a specialist in emergency medicine as board-certified by ABEM and this definition was later expanded to include those certified by AOBEM, pediatric emergency medicine (by ABEM or the American Board of Pediatrics) and the Royal College of Physicians and Surgeons of Canada.
The 1994 Macy Foundation Report entitled The Role of Emergency Medicine in the Future of American Medical Care emerged from a conference requested by SAEM and chaired by the president of the National Board of Medical Examiners. It was initially recommended that emergency medicine board certification be required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to certify comprehensive emergency departments. Unfortunately, the term "board-certified emergency physician" was replaced by "qualified emergency physician" after vigorous lobbying by ACEP to prevent dividing its membership. Some interpret "qualified emergency physician" as a physician trained in any field that chooses to practice emergency medicine.
In contrast, AAEM requires board certification in emergency medicine of each and every full voting member. Currently, the only means of acquiring this is to complete an emergency medicine residency or pediatric emergency medicine fellowship.
The aforementioned Daniels lawsuit was dismissed in 2005, after an unsuccessful appeal by the plaintiffs. AAEM continues to lead efforts preventing the erosion of board certification by unrecognized organizations that hold themselves out as equivalent to ABEM and AOBEM. As of the current printing we are working in California, Florida and Kentucky on this issue.
Since the end of the millennium, there has been a steady rise in the number of large contract management groups (CMGs) acquiring emergency physician contracts. At this point, about one-third of all practicing emergency physicians work for one of them. This degree of "corporatization" far surpasses any other medical specialty and creates a tenuous situation for the future since emergency physician qualifications, working conditions and professional compensation are tied to the bottom line of an economically volatile industry.
AAEM believes that corporate ownership of emergency department contracts represents a violation of the public protections afforded by state prohibitions of the corporate practice of medicine. Additionally, emergency physicians may unwittingly risk their licensure by aiding and abetting the unlawful corporate practice of medicine. The Board of Trustees of the AMA has provided a comprehensive review on the issue as it relates to practicing physicians. AAEM became involved with legal challenges regarding the corporate practice of medicine with large corporations, TeamHealth in California and EmCare in the state of Minnesota. AAEM also participated in a successful action related to the corporate practice of emergency medicine in California involving Catholic Healthcare West.
AAEM has raised concerns with the Office of the Inspector General and the attorney general's office in various states that such corporate employment arrangements may involve prohibited fee-splitting activities under current state and federal statutes. AAEM members are cautioned about accepting employment with corporate groups and AAEM suggests that hospitals examine such an arrangement with due diligence.
AAEM believes that emergency physicians must remain free of corporate influence because of their difficult role as advocates for the under and uninsured patient. The AAEM firmly believes it is in the best interest of the patients to have emergency physicians unencumbered by the profit concerns of a corporation. AAEM is always willing to assist in this matter in order to help emergency physicians secure a physician-owned group, which is the best model for professional satisfaction and care quality.
In 2010, there were 157 allopathic and 37 osteopathic emergency medicine residency programs, which collectively accept about 2,000 new residents each year. Studies have shown that attending emergency physician supervision of residents directly correlates to a higher quality and more cost-effective practice, especially when an emergency medicine residency exists. The resident section of AAEM, which was formed in 1999, became an organization independent of AAEM in 2005 called the AAEM Resident and Student Association (or AAEM/RSA). Its purpose is to provide EM residents a forum and a means to specifically address resident concerns and issues, develop their own programs and services and have a representative that can impact on the direction and mission of AAEM.
One more goal for the next decade is that autonomous academic departments of emergency medicine become universal. Currently, emergency medicine is recognized as an autonomous department in 72 medical colleges, comprising the majority. Medical college deans should be aware that many of the best medical students are pursuing emergency medicine residencies. An SAEM research group recently published findings that autonomous departments of emergency medicine are mutually beneficial for both academic institutions and our specialty with measurable improvements in medical student and postgraduate education, academic productivity and extramural grant funding.