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After the Match

After the Match: The Next Big Thing (Residents' Edition)

Cook, Thomas MD

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doi: 10.1097/01.EEM.0000440695.28893.0f
    Residents, medical students, and staff use the medical simulation center at Tripler Army Medical Center in Honolulu to hone their skills.

    I recently attended parents' orientation at my daughter's new middle school. The principal is an incredible educator and motivational speaker, and he showed a video that many of you have likely seen called “Shift Happens.” (

    The video notes that the top 10 in-demand jobs in 2010 did not exist in 2004. It is a great tool for an educator trying to impress anxious parents that the profession their kids will ultimately pursue likely doesn't have a name yet. But does this really affect a career in medicine? After all, health care has been around for as long as civilization, right?

    Well, not to sound like an old man, but things have changed a lot in just my short time in medicine. When I started in the late 1980s, we had about 20 antibiotics, no fluoroquinolones, albuterol was new, EPs fought for the privilege to intubate, adenosine did not exist, tPA was a new radical and dangerous drug, you could not order an abdominal CT from the ED (and begged for a head CT), we all learned how do to DPLs, and no one had even thought of using an ultrasound machine in the ED.

    My first job when I became an attending in the 1990s was to develop an ultrasound curriculum for residents. I knew absolutely nothing about it, and ended up reading the only textbook available on the subject (thank you, Mike Heller and Dietrich Jehle) while practicing on patients with a dumpy leftover machine found in a closet. Little did I know, but the same experience was happening in other EDs around the nation, and a lot of those EPs were having the same aha moment I was: “This is going be huge.”

    Twenty years later, there are more fellowship programs in emergency ultrasound (90) than EMS (64), emergency pediatrics (50), toxicology (33), or any other niche of our specialty. The ACEP ultrasound section is one of the largest in the college, and if you happened to go to the section meeting during the annual Scientific Assembly, you will find a packed room with hundreds of enthusiastic physicians, nearly all of whom are under 40. Ultrasound companies are springing up left and right in dozens of countries by leveraging the boom in computer technology to create smaller, faster, and cheaper machines. Even the little education company we started in South Carolina 15 years ago with some friends from different residency programs has presented more than 1,000 courses to more than 15,000 physicians. Needless to say, this whole ultrasound thing really took off.

    So I look into my crystal ball to see if I can guess what the next big thing will be, but I want to narrow my focus on something that I would advise an emergency medicine resident interested in an academic career to pursue. This should be something that he considers if he wants in on the ground floor of what will become hugely popular over the next decade and dramatically change the arc of his career. My bet is on simulation medicine.

    Several factors are at play. The first is that regulatory organizations like ACGME and CMS will continue to push for improved quality of care through the measurement of performance and outcomes. This process continuously changes how residents are evaluated on their ability to perform a task in a standardized setting in comparison with their peers and accepted benchmarks. This forces programs to find standardized clinical experiences that level the playing field and valid measurement tools that allow educators to compare apples with apples when judging resident competence.

    The second factor is that practicing on patients is long over. Residents used to be able to attempt invasive procedures on the recently dead. This simply is not acceptable anymore. Finding appropriate opportunities in clinical practice is time-consuming, if not impossible, and this rarely allows the educator to be prepared to observe how the resident is doing. (They should be focused on how the patient is doing.) That creates a need for high-fidelity simulators that can be reset as many times as needed for the learner to acquire the skill and achieve clinical competency. Training with simulation in play is no longer based on chance encounters, and competency is no longer based on the length of time spent in training.

    Medical centers are pouring a lot of money into simulators as a way to train and certify a wide range of health care providers efficiently. Personnel cannot work and hospitals and clinics cannot operate (and make money) without this capability. I visited the simulation center at Indiana University a few years ago. It occupies a couple of floors in a large academic building, and one large room has an ambulance in it. This is even more impressive when you consider it is on the sixth floor. I asked how you get an ambulance in a room like this, and they said it was dropped in by helicopter when the building was being constructed. These guys struck me as being pretty serious. High stakes credentialing using simulation technologies is going to be a major player in the years to come, and our department has access to a fully resourced, accredited simulation center under the direction of one of our program's faculty.

    Stop to consider, though, who actually manages all these (expensive) simulation centers. The folks running them now typically do not have formal fellowship training in simulation medicine. In fact, only 14 fellowships exist, which, given the number of centers in operation and those that will be created in the future, is woefully inadequate. I realize lots of hurdles and bumps are in the road, but this is going to happen, and the combination of skyrocketing computer technology and market forces will create exciting opportunities for those who have the vision to travel down this professional path.

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