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After the Match: An Emergency Medicine-Anesthesiology Residency? Be Careful What You Ask For

Cook, Thomas MD

doi: 10.1097/01.EEM.0000461008.92588.36
After the Match

Dr. Cookis the program director of the emergency medicine residency at Palmetto Health Richland in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (http://emergencyultrasound.com). Friend him athttp://www.facebook.com/3rdRockUltrasound, follow him @3rdRockUS, and read his past columns athttp://bit.ly/CookCollection.

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I routinely receive email surveys about resident education, and I was recently asked for my opinion on the formation of a new type of residency training that combined emergency medicine and anesthesia. This would be similar to other combined training programs such as emergency medicine/internal medicine and internal medicine/pediatrics.

Being a bit older, however, I have the perspective of time. I went through my residency training in the early 1990s, and I remember that everyone then was excited to be using new drugs to help with intubations. A few years earlier, the hospital had allowed emergency physicians to use paralytic medications. Before this, the anesthesiologists at that hospital had deemed these drugs too dangerous (or perhaps they meant too complicated) for emergency physicians to use. If this sounds patronizing, it's because it was.

Anesthesiologists during this time were also eviscerating their specialty by creating nurse-anesthetists. These CRNAs allowed the physician-anesthetists to run more operating rooms and keep more of the money for themselves. Many hospitals eventually realized that it did not necessarily take a physician to provide anesthesia, and the demand for physician-anesthetists shrank. This, in turn, decreased the need for anesthesia residency programs. (The one at my current hospital closed in the 1990s.) Entire schools cropped up just to train nurse-anesthetists. Currently, there are 114 of these schools in the United States.

What do folks do when the bottom drops out, and they cannot find all the work they want or need? They look for the winners. They look for the organizations where demand is high, supply is low, and all the best people are joining. It did not take long before anesthesia called on the hippest new specialty. Anesthesia began by asking the American Board of Emergency Medicine to allow its residency graduates to sit for the emergency medicine boards. They reasoned that anesthesiologists were already trained in all the procedures to be an emergency physician. Of course, this overlooked the fact that procedures are just a small fraction of the skills needed to be competent in an emergency department. And were they really prepared to work with patients who would be awake (and often argumentative) the entire time they were being treated?

Not surprisingly, this proposal was shot down. But now emergency medicine is considering a new idea, and it generates a lot of questions. What is the benefit to emergency medicine? What is the benefit to anesthesia? What is the benefit to the patients?

Anesthesiologists in my experience are often loath to come to the ED (especially if you want them to place a blood patch for a post-LP headache). I don't blame them; they are trained to operate in controlled settings under optimal conditions. Running to the ED to intubate a guy puking blood, beer, and pizza is not their thing. Do they look at emergency medicine as a way to improve the overall care they can provide to patients or a way to find work when all the anesthesia gigs in town are taken and their kid just got accepted to an Ivy League school?

On the other hand, would emergency physicians look at anesthesia as a way out of the chaos of the ED and the long-term effects of shift work on their health? Would they be able to transition to a more mellow work life as they aged? I guess it sounds OK, but it really does not strike me as realistic without careful planning.

All of this obscures the incredible irony that so many specialties took shots at us in the past and now look to emergency medicine for leadership and career opportunities. Very few would have predicted this all those years ago. Emergency medicine seems to have made a lot of good decisions, but more likely, this success can be attributed to its natural ability to disrupt the house of medicine more than any other specialty in our lifetime.

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