Academic Emergency Medicine's Future - Wiley Online Library

ACADEMIC EMERGENCY MEDICINE • February 1999, Volume 6, Number 2

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SPECIAL CONTRIBUTIONS Academic Emergency Medicine’s Future THE SAEM TASK FORCE ON EMERGENCY MEDICINE’S FUTURE: KENNETH V. ISERSON, MD, MBA, JAMES ADAMS, MD, WILLIAM H. CORDELL, MD, LOUIS GRAFF, MD, JOHN HALAMKA, MD, MS, LOUIS LING, MD, W. FRANK PEACOCK IV, MD, DAVID SKLAR, MD, TOM STAIR, MD

Abstract. Emergency medicine (EM) will change over the next 20 years more than any other specialty. Its proximity to and interrelationships with the community, nearly all other clinicians (physicians and nonphysicians), and scientific/technologic developments guarantee this. While emergency physicians (EPs) will continue to treat both emergent and nonemergent patients, over the next decades our interventions, methods, and place in the medical care system will probably become unrecognizable from the EM we now practice and deliver. This paper, developed by the Society for Academic Emergency Medicine (SAEM) Task Force on Academic Emergency Medicine’s Future, was designed to promote discussions about and actions to optimize our specialty’s future. After briefly discussing the importance of futures planning, it suggests ‘‘best-case,’’ ‘‘worst-case,’’

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MERGENCY medicine (EM) will change over the next 20 years more than any other specialty. Its proximity to and interrelationships with the community, nearly all other clinicians (physicians and nonphysicians), and scientific/technoFrom the Section of Emergency Medicine and the Arizona Bioethics Program, University of Arizona, College of Medicine, Tucson, AZ (KVI); Department of Emergency Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (JA, TS); Department of Emergency Medicine, Methodist Hospital of Indiana, Indianapolis, IN (WHC); Department of Emergency Medicine, Northwestern University School of Medicine, Chicago, IL (LG); Division of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA (JH); Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN (LL); Department of Emergency Medicine, Cleveland Clinic, Cleveland, OH (WFP); and Department of Emergency Medicine, University of New Mexico College of Medicine, Albuquerque, NM (DS). Received July 9, 1998; accepted October 15, 1998. Reviewed by the SAEM Board of Directors, June 10, 1998. Address for correspondence: Kenneth V. Iserson, MD, MBA, Section of Emergency Medicine and the Arizona Bioethics Program, University of Arizona College of Medicine, Tucson, AZ 85724. Fax: 520-626-2480.

and most probable future courses for academic EM over the next decades. The authors predict that EPs will practice a much more technologic and accurate form of medicine, with diagnostic, patient, reference, and consultant information rapidly available to them. They will be at the center of an extensive consultation network stemming from major medical centers and the purveyors of a sophisticated home health system, very similar to or even more advanced than what is now delivered on hospital wards. The key to planning for our specialty is for EM organizations, academic centers, and individuals to act now to optimize our possible future. Key words: emergency services; health planning; forecasting; health services needs and demands; telemedicine; academic emergency medicine. ACADEMIC EMERGENCY MEDICINE 1999; 6:137 – 144

logic developments guarantee this. While emergency physicians (EPs) will continue to treat both emergent and nonemergent patients, over the next decades our interventions, methods, and place in the medical care system will change markedly from the EM we now practice and deliver. As hospitals are being transformed into clusters of outpatient services (reference laboratory, imaging, procedure rooms, parking lot), EPs, more so than most others in health care, recognize the trend toward service, convenience, and availability. EPs adapt rapidly to change, in part because they have little capital tied up in real estate, equipment, and established practices. As EDs evolve, patients will still be offered the services they want beyond simple emergency care. These include convenience, anonymity for ticklish and insurancerate-sensitive problems, lack of required continuity of care, freedom from consequences and follow-up, and an alternative method of health care delivery to compensate for not scheduling primary care visits, filling needed prescriptions, or following their primary physicians’ suggestions.

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Emergency physicians will practice a much more technologic and accurate form of medicine, with diagnostic, patient, reference, and consultant information rapidly available to them. They will be at the center of an extensive consultation network stemming from major medical centers. They will also be recognized as key diagnosticians and treatment deliverers, as well as the purveyors of a sophisticated home health system very similar to or even more advanced than what is now delivered on hospital wards. Low-probability/high-impact events outside of medicine will occur. The fact that they are lowprobability makes them ‘‘laughable’’ until they occur. That these events will cause significant changes in our health care (and other) environment if they do occur requires that we look at them seriously. With the passage of time the likelihood of any ‘‘low-probability’’ event’s occurring increases, eventually to the point that it becomes a probable occurrence. No matter the source, the advances in biotechnology, pharmacology, information technology, and economics of EM over the coming decades will also create more ethical dilemmas for practitioners and patients than we can imagine. This paper was produced through the efforts of an ‘‘expert group’’ assembled by the Society for Academic Emergency Medicine (SAEM). The multiple views expressed by the group’s members and combined in this document should be seen as the basis for discussions about and actions to optimize our specialty’s future. This paper first briefly discusses the importance of futures planning, then suggests what EM’s future will be in ‘‘best-case’’ and ‘‘worst-case’’ scenarios over the next decades. Finally, it examines the EM’s most probable future course.

THE IMPORTANCE OF FUTURES PLANNING There is no more powerful engine driving an organization toward excellence and long-range success than an attractive, worthwhile, and achievable vision of the future, widely shared.1 Depending on one’s view (and, in some cases, one’s vested interests), the future of health care described in this paper represents either a marvelous opportunity for innovative change or dismal rejection of current norms. It posits neither a utopian future nor pervasive gloom. The picture is definitely mixed and, in a large part, the future depends on what we do now. Today’s decisions and our willingness to plan for future developments will either enhance or tarnish our futures. There are many paths to the future; it is up to us to take the necessary steps to ensure the ‘‘preferred’’ future.

Iserson et al. • ACADEMIC EMERGENCY MEDICINE’S FUTURE

‘‘Few good things in human affairs ‘just happen.’ In the majority of cases, things happen only when people dream of a better tomorrow, decide they truly want to make it happen, and then act to turn their dreams into reality. That’s what vision is all about . . . Since human behavior in organizations is very much shaped by a shared vision of the future, developing and promulgating such a vision may well be the highest calling and truest purpose of leadership.’’ 2 We cannot predict the future, but we must recognize that our actions today will shape our future. We must act, rather than react; be aware, rather than bury our heads in the sand. Organizations such as SAEM increasingly will need to take the long view in order to research, develop, rehearse, and implement alternative futures scenarios. Such scenarios, linked to a clear sense of trends and strategies based on alternative scenarios, enable us to shape the future we prefer. Initially, we need to consider the implications of current health care delivery systems, medical science, the economy, and social changes, for EPs and EM, and determine whether they will remain the same, improve, or worsen. However, future planning is an ongoing process. As our environment changes, we must refine our predictions, alter our assumptions, and redevelop our alternative future scenarios. Such skills and ongoing scenario development will address: 1) developing the long view; 2) managing constant change; 3) thriving in the midst of uncertainty; 4) articulating a powerful shared vision; and 5) redefining what it means to be an EP and medical educator.

MOST FAVORABLE FUTURE The following events represent the optimist’s view of EM’s future. It is a rosy scenario based on the premise that all or most of the coming decades’ changes will impact EM in a favorable way. Emergency medical services (EMS) will use ‘‘demand management’’ to better allocate resources, in some cases coordinating with managed care providers. In this system, patients will call telephoneresponse centers that have expanded from the current nurse-staffed centers. After accessing the patient’s medical records, refined protocols will be used to dispatch the most efficient care. One call might result in the pharmacy’s delivering a nonsteroidal medication, while another might result in a cab ride to an office appointment the next morning. Ambulances will be dispatched only for the minority of cases that require urgent interventions or when the severity of illness cannot be determined. For an expanding number of conditions, patients may not be transported to the nearest hospital, but to facilities providing special services or continuity.

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Computerization will allow EPs to spend less time recordkeeping. It also will provide primary care – ED continuity because of easy access to patients’ records. New systems will emerge that support and guide physicians’ clinical decisions using real-time probability calculations based on previous similar patients and an automatic comparison of the computerized ED record with existing medical literature. Telemedicine will be ubiquitous, with almost all EDs linked in a network with hospitals competing with each other to offer even more extensive computer networks. Most patient transfers will include a review of telemedically-transmitted radiographs and photographs, and transfers often will be avoided because telemedicine consultations will assist on-site physicians to manage complicated patients. Most continuing education will be completed through telemedicine-type conferences, many accessed via home computers. Even at the smallest hospitals, practitioners will have access to medical center education at very low prices. Emergency radiographs, CT scans, and other imaging and diagnostic tests will be interpreted in real time by radiologists, often at regional or national centers, available 24 hours a day. Graduate medical education funding for EM will continue at the current level. Increases will occur slowly if at all, due to organized medicine’s political activities, although most other specialties will have fewer residency-training positions. EM education will expand as its scope of practice expands. Residents will be trained in observational medicine, to run chest pain centers, to perform ultrasound examinations, to interpret CT scans, and to perform in-depth cardiac assessments. Some programs will include training in telemedicine. Eventually all EM residency training programs will become four years long because of the specialty’s ever-increasing scope of demands. Because of their versatility, EM graduates will still be able to get jobs. The training of EM residents will be unencumbered by the changes in referral patterns, network development, corporatization of medical practice, and managed care. Many patients will still need emergency care and seek that care in the tertiary institutions where EM residencies have been established. EM residents will continue to acquire broad skills to handle the vast spectrum of emergencies. The complexity of EM’s role as a central hub of the health care system will still require highly trained EPs for their diagnostic and management skills. Primary care specialties and EM will cooperate to provide continuous (24 hours a day/seven days a week) care. During work hours, EDs will see walk-in overflow and patients too sick for tightly scheduled primary care clinics. More clinics

will be open evenings and weekends to accommodate working patients. After normal hours, EDs will cover everything, but to maintain improved continuity and economy, they will have access to patients’ medical records, office-appointment schedules, and on-call primary physicians. Physician extenders will be used only to augment the physician’s role in the ED and in the out-of-hospital and home care settings. EPs will be viewed as the point of definitive expertise for diagnostic evaluation of the most complex patients. The depth and breadth of the specialty will continue to grow. With funding of EM education and practice relatively static, academic EDs will rely more heavily on outside contracts to augment their support. Some states will become more active in financing and controlling medical education. EPs will still receive some favor because of the perception that those services are in high demand. Eventually, the large managed care companies will break apart as dissatisfied patients start to pay out of pocket for highly valued services and demand government support for many medical programs. The aging population will recognize the value of well-trained physicians and support public funding for training programs. Government and private funding will increase for EM research. A separate National Institutes of Health study section will be established, with some projects and funding in conjunction with the Centers for Disease Control and Prevention. As EM becomes recognized as the hub of the health care system, research dollars will flow more readily in order to improve the quality and expand the scientific basis for more of our diagnostic and treatment standards. Emergency medicine organizations will have fewer disagreements as more and more practitioners are residency-trained and share common values. The largest organizations will continue to gain members and become more collaborative as they recognize their common goals and outside threats. A few seminal events will enhance the status of and the ability to practice and teach EM by demonstrating its importance (probably through problems that arise when it is absent or inadequate) to our society and societies around the globe. EM will become a priority for federal, private, and commercial research funding.

LEAST FAVORABLE FUTURE Some events may turn out in ways that approximate what we see as the worst possible outcome for EM. Those who are positioned to ameliorate or even take advantages of the changes will survive. One purpose of futures planning is to make changes now to avoid the worst possible outcomes.

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If the following events occur over the next decades, the future will disfavor EM. In this scenario, the richest in our society will receive high-tech fee-for-service house calls. The poor will access medical care by calling 9-1-1, even for nonemergency problems. Municipal EMS will crumble from overdemand and underfunding, but the problem will remain invisible to taxpayers. Emergency department charts will be the last part of the medical record to be universally computerized, often still scrawled in ballpoint pen on carbonless forms — which means they will often be lost, irrelevant, or ignored, and the services they represent will remain unreimbursed. Hospital administrators will see EDs as black holes of debt and malpractice. As telemedicine becomes more important, with video conferencing and video communications, most EPs will be left out of the system. EPs will become conduits between patients and physicians, while their own roles will be devalued. Telemedicine will be used by subspecialists to consult in EDs 24 hours a day, with few interested in seeing even very ill patients onsite. EPs’ independent role will decrease as specialists increasingly ‘‘examine’’ their patients and the data via telemedicine links. The need for rural EPs will decrease as non-EPs from large cities make direct visual contact via telemedicine with physician assistants, nurses, and patients in smaller hospitals. Funding expensive training programs will become prohibitive. Extreme funding cuts will result in the loss of a substantial number of EM residency positions and the withdrawal of institutional support for planned training programs. Sponsoring hospitals and medical schools will not actively support newly formed and politically weak departments and divisions of EM, causing a reduction in the number of programs and training slots. Other specialties will regain an interest in EM fellowship training so that their graduates can have an increased number of and more varied job opportunities. Managed care, profit/loss, and financial sessions will be incorporated into residency training as residents become primarily concerned with personal economic survival. EM residents will have inadequate experience in minor ambulatory care since few minor emergencies will present to the ED. Many EM training programs will become nonviable as patients are diverted away from EDs. Academic EDs increasingly will manage more private EDs, using their additional clinical income to support educational programs. Community hospitals will become ever more important in financing education and residents will spend more time in the community, in part to provide service to support their education. As a result, EM residents will be trained either in preceptor-like fashion by EM attendings in small community residencies or in


large public hospitals where they will provide the bulk of the institution’s medical care. Academic physicians’ incomes will continue to decrease as resources are diverted to pay for training programs, dissuading many from embarking on academic careers. Eventually, the support for EM education and research will evaporate. Public medical schools will continue to merge or close. In the ED, the physician will bear the final responsibility, but physician extenders, nurses, and automated machines will accomplish most patient care tasks. The primary practice focus will narrow, as only the very sickest patients will come within the realm of EPs. Many hospitals will be built without full-service EDs. Mergers in managed care will result in a few contract groups’ owning all EP jobs. Fewer patients will be referred to EDs as primary care physician/physician assistant or nurse practitioner teams will do point-of-care testing and on-site therapy and provide home care. Capitated primary care physicians will order radiology and laboratory studies 24 hours a day without ED involvement. Study results will be called to the primary physician, who will either admit the patient directly to an inpatient resident or hospitalist, or refer the already worked-up patient to the ED. The outpatient setting, not the ED, will become the setting for patient evaluation. The ED will care largely for uninsured patients, making it economically nonviable. New organizations will emerge that represent the increasing diversity of EM. More than a halfdozen small EM groups, with specific narrow agendas, will waste considerable energy bickering with each other. EPs will split up into small factions, making it difficult for legislators and the public to hear a unified voice. The academic societies will break into smaller, more narrowly oriented groups. These small societies, specializing in chest pain, asthma, head injury, toxicology, observation medicine, informatics, and EMS, will win greater loyalty from their members than the largest organizations, which will start to represent a lower percentage of EPs. Older EPs will leave the mainstream EM organizations (often leaving medical practice), and increasing competition will develop between the organizations for EPs’ attention and dues dollars. The new organizational leaders will have little in common with EM’s prior leaders or with each other. There will be no growth in research funding for EM as academics turn their attention to funding the medical school departments with clinical services. A very small group of EP researchers will obtain some extramural support and minimally advance the EM research base. One or more events will occur that destroy the ability to deliver effective emergency medical care


to most of the U.S. population. These events, such as a release of biological weapons, new emerging drug resistance, or devastating infectious agents, will destroy substantial parts of the government, social, and medical infrastructures, sharply diminishing the number of trained emergency medical personnel.

MOST PROBABLE FUTURE The term ‘‘most-probable future’’ does not mean certainty; a cone of probability surrounds any prediction. The more distant the events, the greater that cone and less probable the outcome. In other words, don’t put all of your planning ‘‘eggs’’ in the single basket of the ‘‘most-probable future.’’ In our immediate future, EM will continue to see an increase in uninsured and nonpaying patients, while paying/contracted patients will be diverted to other treatment options. Financially lessdesirable patients may not actually be diverted from specialists, but be passively guided to the ED for care. Increasing fiscal pressure from thirdparty payers will require other specialties to increase productivity to maintain their current financial position. The competition for ‘‘paying customers’’ will therefore increase as other specialties devise innovative strategies to ‘‘capture’’ these patients and shift costs to EDs. These methods include actively diverting (e.g., sending vehicles for) noncritical patients to their own clinics; expanding office hours; demanding more complex and costly ED evaluations prior to consultation or admission; using the ED rather than admissions for limited procedures (such as transfusions); and establishing stringent review mechanisms before EPs can perform high-overhead low-reimbursement diagnostic testing and therapy (i.e., complex imaging, expensive laboratory tests, or nonemergent invasive procedures). Increasing lengths of stay for low-reimbursement ED patients will lead to functional overcrowding and an inability to increase the ED productivity. EM reimbursement will diminish. There will be a small decrease in EM residency training positions as new residency formation slows and federal dollars to support continuing medical education diminish, despite local and national political action to preserve these slots. New programs will develop slowly, and occasionally a program will close. While EM residents will be trained in key aspects of clinico-economic management (i.e., incorporating economic factors into clinical decision making), the primary focus will remain the acquisition of emergency medical skills. The traditional skills inventory will expand and mutate as the clinical environment changes. Med-

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ical institutions, patients, and colleagues increasingly will expect EPs to make correct diagnoses followed by appropriate and cost-effective dispositions. Five years from now, managed care will be at its peak, with more people enrolled than at any other time. These institutions will strive, whenever possible, to decrease ED patient visits, hospitalizations, and specialty consultations. Hospitals and systems will have significantly downsized. Third-party payers, especially the federal government, will completely control all aspects of health care funding. Fewer ED patient visits, with an increasing illness severity and pressures for extensive ED evaluations, will result in functional ED overcrowding. EDs will manage an increasingly complex but diminishing patient census with limited resources, as EPs face a continuing decline in reimbursement. The EMS system will continue its slow progression from municipal fire departments to privatized contract services in many regions. In the few places or organizations in which it exists, telemedicine will enhance the abilities of EPs to manage on-scene emergencies, but limited financing slows implementation. Available new technologies and procedures will include live on-scene video feeds, 12-lead ECGs transmitted to base stations, onscene blood tests, adult interosseus infusions, bypass protocols to specialized centers for heart attacks and strokes, and paramedic-worn computers that generate automated communications and run sheets. Health care organizations will begin to effectively use intranets. Patients with chronic conditions will maintain telemedicine links to their providers, often over cable television lines, so many routine clinic visits, such as to adjust medication dosages, query or reset pacemakers, or measure pulmonary functions, will become unnecessary. This will give EPs their first opportunities in their new role as long-distance (and after-hours) home health care providers. EDs will also become the test areas for new clinical information systems. Health care systems analysts and providers will recognize that computer hardware and applications tailored to the needs of EDs (with rapid response times, rare downtimes, a variety of users, and a variety of needs— all within a hostile hardware environment) can probably be cloned for other settings, but not vice versa. Medical informatics will continue to be dominated by billing concerns. Protecting confidentiality and privacy, however, will become a major public concern. The EP workforce will increase so that graduating residents will have difficulty finding practice positions, especially in desirable locations or with groups they perceive as being fair and honest. Due

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in part to the saturation of EPs’, residency applicant quality will diminish. Faculty physicians will become more involved with each patient, giving residents less autonomy. Government support for education will diminish even further, causing the number of residencies to drop. With the general physician surplus and telemedicine, more radiologists and cardiologists will spend nights in the hospital or otherwise become available to immediately perform and interpret imaging and other diagnostic tests. Consequently, training in these areas will be compromised. Training in thoracotomies and cricothyrotomies will continue to decrease. Emergency physicians will increase their professional reach by providing services to occupational medicine clinics, nursing homes, and hospices. EDs will continue to sprout urgent care units, chest pain units, and observation units, albeit with mixed success. Most nonrural EDs will have only physician extenders (physician assistants or nurse practitioners) to provide walk-in or fast-track services, with sporadic physician supervision. Most freestanding urgent care centers will have one physician, who is not always on site, supervising many nonphysicians. Emergency department staffing will still strain with the tension between ‘‘consumerism,’’ which demands increasingly improved quality of services, and ‘‘managed care,’’ which demands increasingly lower costs. Patient care will suffer. Cost efficiency will result from improved productivity (e.g., bedside 5-minute, $20 tests rather than laboratory 60minute, $60 tests) and from replacing higher-cost labor (e.g., trained EPs and nurses) with automation or lower-cost labor (e.g., physician assistants, nurse’s aides, and technicians). The loss of walk-in and nonurgent services to physician extenders will have a relatively minor impact, since these patients require less than half the physician services and bring in proportionally much less revenue than an ED patient. More hospitals will close. Those hospitals with very active EDs, however, will generate community and governmental support to remain open. Many urban EDs will merge into mega-departments, eschewing institutional provincialism for economies of scale. In these settings, especially those with significant numbers of lower-acuity patients, other specialties will erode EM’s primacy by seeing their unique patient subsets. EPs will be left to treat patients outside of the specialists’ expertise. Institutions will save money and other departments and practices will enhance their revenue by developing ED satellite operations. In addition, an increasing number of ‘‘hospitalists’’ will care for their patients in the ED and use EDs to screen patients prior to inpatient admission. These physicians, with a limited repertoire of


emergency skills (pediatricians, internists), will not staff EDs cost-effectively when the volume of cases drops below a certain threshold. Since census drops during the late night, EM will become predominately a nocturnal specialty. Emergency medicine research, research forums, publications, practice applications for research, and the crossover of EM research into other specialties will continue to increase. Funding for research will grow more slowly, and will focus on the popular areas of injury prevention, domestic violence, and women’s and children’s health. With better communication systems and patients’ increasing access to scientific information, the lag time for the discovery of new clinical innovations to practice will be shortened. EM’s clinical practice will rely heavily on scientific evidence rather than on inherited traditions. Computerization of clinical records will create new opportunities for quantification and the application of artificial intelligence. However, billing considerations will still drive the implementation of most ED information systems. Internationally, EM educators, especially bilingual individuals (EPs, nurses, and paramedics) from countries with highly developed systems, will be in demand. International EM conferences will become more common. Ten to fifteen years in the future, the medicine workforce will be large, but with the aging population, health care will consume an ever-increasing share of the gross national product. EDs will provide care to large numbers of sick patients. The need to ‘‘hospitalize’’ patients will rebound because of the increasing number of sick, elder people. Many of these non-intensive-care-units, nonsurgical ‘‘admissions’’ will be treated at home via telemetric monitoring and therapy adjustments. EPs act as this system’s hub, supervising an extensive home health care system and controlling large numbers of mid-level providers and low-level onsite aides. Some ambulances will have imaging capabilities, so fewer patients will need to be transported to hospitals as more diagnoses and definitive treatments are provided under remote physician control. On-site electronic payment will reimburse EPs for these services. High-complexity EP services, such as the evaluations and management of serious acute disorders, will remain the task of physicians because of ‘‘consumerism’s’’ demand for high-quality service. By this time, the EM workforce will have aged, and many trained EPs will work either part-time in EM or in non-EM fields. The oldest residencytrained EPs will retire from active practice earlier than might be expected due to the demands of long overnight hours and rotating schedules. Even so, an oversupply of EPs will decrease the specialty’s popularity despite higher salaries. EM will no

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longer be a highly sought-after specialty choice for medical students. Resident salaries will stagnate and most will join unions to prevent further salary and benefit losses. Preparation for practicing telemedicine in addition to EM will require intense extra training, similar to current fellowships. Telemedicine will be in such demand, however, that EM residencies will change to four or five years to accommodate these requirements (similar to the current combined pulmonary/critical care fellowships or the anatomic/clinical pathology residencies). Emergency physicians will provide medical observation service as one-day hospital stays are eliminated and the financial rewards of this service increase. There will be more work and revenue to support the physician staff. EP staffing needs will stabilize as physicians are reimbursed for their many services, including toxicology, hyperbaric medicine, occupational health, sports medicine, and telemetry – home health care. Some EPs will more actively pursue practices outside EDs and urgent care centers, such as cruise ship and expedition medicine. Emergency departments will weather the political and economics storms by becoming the key to hospitals’ economic survival. With increases in home care, the EDs will become a central point for complex patient workups. As sick patients are managed at home and discharged earlier from the hospital, EDs will serve as a central resource for patients whose conditions deteriorate. Busy primary physicians will look to the ED for evaluation of complex patients. This will involve developing ‘‘observation areas’’ to determine the necessary level of home or hospital intervention. EPs will need to work closely with primary physicians, sometimes sharing financial risk in physician-hospital. Patients will finally benefit from the efficiencies of a completely electronic medical record system; they will no longer need to re-register for each provider and repeat their medical histories. Drug – drug interaction rates, unnecessary tests, and medication errors will decrease by 10%. All parties will finally agree on methods for ensuring patient record security, standardization of data, and development of a medical information infrastructure. Confidentiality and regulatory issues, previously a major barrier to sharing health care information between health care delivery sites, across state lines, and internationally, will be eliminated for most Western countries. Clinical record databases will be routinely used to spot trends and calculate probabilities for clinical-decision algorithms. With the development of data-acquisition standards, data from large numbers of EDs will be routinely pooled to conduct population surveys and epide-

miologic surveillance. Researchers will develop new skills and technologies to merge and analyze these data ‘‘goldmines.’’ Medical records will be centralized in every country except the United States. There will be a qualitative and quantitative growth of EM training programs in foreign countries. This will occur because of: 1) increases in trauma as more motor vehicles are purchased and as violence increases as weapons continue to proliferate; 2) an emulation of the very successful EM programs and specialty in the United States, Canada, and elsewhere; 3) expanding economies and different lifestyles make 24-hour access to medical care vital; 4) awareness of the specialty’s importance as local ambulance services and the general physician population respond poorly to natural and manmade disasters; and 5) newer diagnostic and therapeutic technologies in EM require increasing amounts of education to master. Telemedical links among various countries and EM centers of excellence will develop and flourish, increasing the need for bilingual clinicians. Air ambulances and international ambulance services will improve, proliferate, and decrease in price. EM academics will begin to conduct research studies with wide international cooperation. Excellent clinical and systems ideas will flow more easily between EM practitioners in various countries. Some clinical and nonclinical services will be outsourced to countries where they can be done more economically. EDs will be seen as key sentinel sites for the recognition of new infectious diseases. National health care will develop in increments, resulting in confusion, conflicts, and increased costs. Increasing numbers of Americans will be covered by health insurance — coverage that is insufficient for most, but an excellent improvement for an underserved minority. With increasing computerization, standardization, and centralization, EPs will lose autonomy while gaining influence and respect within the health care system. Increased outcome-based measurements will guide much of the diagnostic and therapeutic interventions now done on a case-by-case basis. Overall, changes in the types of illnesses and injuries will alter emergency medical care delivery, the basic educational milieu, and the settings in which health care is delivered. Yet EPs will continue to deliver emergency care when necessary and to be the safety net for those who have no other access to an underfunded health care system.

AN ACTION AGENDA Our responsibility as emergency medical educators and researchers is to prepare our graduates for their future careers. Our professional organiza-

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tions, with their greater resources, wider vision, and opportunities for more diversified input, must assist us in this difficult process. Our professional organizations have a responsibility to develop plans to address possible futures, so we can try to ward off the worst possible eventualities and act immediately as our professional environment changes. Yet our organizations often become distracted by ‘‘putting out fires’’ rather than helping EM researcher-educators to define, anticipate, and restructure our professional future. We cannot afford to make future assessment and planning an occasional afterthought. Rather, we must recognize its centrality to our existence. As EM professionals, educators, and researchers, we must actively participate in futures planning. References 1. Nanus B. Visionary Leadership: Creating a Compelling Sense of Direction for Your Organization. San Francisco: Jossey-Bass, 1992, p 3. 2. Nanus B. Leading the vision team. Futurist. 1996; 30(3): 21 – 3.

Resources General 1. Bishop P. Thinking like a futurist. Futurist. 1998; 32:39 – 42. 2. Bowles LT, Sirica CM (eds). The Role of Emergency Medicine in the Future of American Medical Care. New York: Josiah Macy, Jr. Foundation, 1995. 3. Rorrie CC. The future of emergency medicine. Ann Emerg Med. 1997; 30:749 – 53. 4. Smith MS, Freied CF. The next-generation ED. Ann Emerg Med. 1998; 32:65 – 74. EMS 5. Delbridge TR, Bailey B, Chew JL, et al. EMS agenda for the future: where we are . . . where we want to be. Ann Emerg Med. 1998; 31:251 – 63. 6. Dickinson ET, Verdile VP, Lostyun CT, et al. Geriatric use of emergency medical services. Ann Emerg Med. 1996; 27: 199 – 203. 7. Spaite DW. Emergency medical services systems research: problems of the past, challenges of the future. Ann Emerg Med. 1995; 26:146 – 52.


Education 8. Inglehart J. Forum on the future of academic medicine: session III — getting from here to there. Acad Med. 1998; 73: 146 – 51. 9. McCabe JB. Emergency medicine and the academic health center. Ann Emerg Med. 1997; 30:773 – 5. 10. Munger BS, Danzl DF, Reinhart MA. The future of the certification system in emergency medicine. Ann Emerg Med. 1997; 30:776 – 8. Information Systems/Telemedicine 11. Hamalka JD, Kohane IS, Szolovitts P, et al. Cross-institutional electronic medical records for emergency care [abstract]. Ann Emerg Med. 1997; 30:387. 12. Institute of Medicine, Committee on Improving the Medical Record. The Computer-based Patient Record: An Essential Technology for Health Care. Washington, DC: National Academy Press, 1991. Emergency Medicine Workforce 13. Brillman J, Graff L, Dunbar, et al. American College of Emergency Physicians Section of Observation Services. Management of observation services. Management of observation units. Ann Emerg Med. 1995; 25:823 – 30. 14. Graff L, Wolf S, Dinwoodie R, Buono D, Mucci D. Emergency physician workload: A time study. Ann Emerg Med. 1993; 22:1156 – 63. 15. Moorhead JC, Schafermeyer RW, Rorrie CC. Key issues in emergency medicine workforce planning. Ann Emerg Med. 1997; 30:765 – 72. Scope of Practice 16. Kellermann AL. Clinical emergency medicine, today and tomorrow. Ann Emerg Med. 1995; 25:235 – 8. 17. Williams RM. The costs of visits to the EDs. N Engl J Med. 1996; 334:642 – 6. Research and Science 18. Fontanarosa PB. Scientific publications in emergency medicine: imprint on the future. Ann Emerg Med. 1997; 30: 782 – 4. 19. Ling LJ. The future of emergency medicine research. Acad Emerg Med. 1998; 5:147 – 51. 20. Safran C. Using routinely collected data for clinical research. Stat Med. 1991; 10:559 – 64. 21. Tierney WM, McDonald CJ. Practice databases and their uses in clinical research. Stat Med. 1991; 10:541 – 7. 22. Tierney WM, Miller ME, Hui SL, et al. Practice randomization and clinical research: the Indiana experience. Med Care. 1991; 29:JS57 – 64. Rare Events 23. Halal WE, Kull MD, Leffmann A. Emerging techologies: what’s ahead for 2001 – 2030. The Futurist. 1997; 31(6):20 – 8. 24. Mautner M. Human values and technical advances. Futurist. 1992; 28(4):41 – 4. 25. Rosenberg N. Why technology forecasts often fail. Futurist. 1995; 29(4):16 – 21.