SEPTEMBER / OCTOBER 2003

FEATURES

 

Emergency Medicine training initiative continues in Italy

The Beth Israel Deaconess Medical Center Department of Emergency Medicine (BIDMC-EM), with support in curriculum development and quality management from Harvard Medical International, is making progress towards launching the first residency program in emergency medicine offered in Italy. The program is part of a nationwide effort to make the emergency physician a recognized professional responsible for the initial diagnosis and treatment of critically ill patients, and to define and implement specialized training for this emerging specialty.

Dr. Stephen Traub (left) is among those from BIDMC-EM who have visited Italy as an attending physician during the initial training course.

Emergency medicine (EM) only emerged in the United States a little over three decades ago and is rapidly taking hold throughout the world. The events of September 11th prompted Italy’s Ministry of Health to look closely at the state of disaster management and health care and identify areas that required improvement. The Tuscan government then issued a directive requiring training in emergency medicine. With the government not just on board, but actually driving a change in policy, the Ministry of Health looked to make emergency medicine a recognized specialty in the Italian health care community.

Enter Kevin Ban, an energetic third-year resident at BIDMC-EM, who had helped plan a disaster management conference hosted by Careggi Hospital. The success of that conference prompted another idea. In 2002, said Ban, “We decided that we could create a training model for emergency physicians at Careggi Hospital.” Careggi is the teaching hospital of the University of Florence.

Designing a model for emergency medicine training
Today a rotating team of emergency physician-instructors from BIDMC-EM are building the foundation for a residency program whose long-term goal is to prepare Italy to certify in emergency medicine all of the approximately 500 physicians in Tuscany. Currently, the team is leading a core group of 24 physicians through an intense nine-month course in Italy to expand their scope of practice. The course, which follows a train-the-trainer model, combines clinical rotations and a series of lectures, delivered by both Italian doctors and the core group of BIDMC-EM physicians.

These pioneer physicians will help train the first “fellows” who specialize in emergency medicine (The target launch date for that program is February 2004.). The course began in June, after representatives from BIDMC-EM, including Ban, spent four months observing how emergency medical care was provided in Tuscan hospitals and identifying critical education areas.

HMI is working with the team from BIDMC-EM to design the residency curriculum and is providing benchmarks for measuring the quality of patient care. This work encompasses the development of case study courses for emergency medicine and faculty development, as well as the design and implementation of testing methodologies for measuring and evaluating the training courses. Dr. Sharon Kleefield, HMI director of healthcare quality, recently visited Careggi to lecture on measuring healthcare quality and describe how it is being developed with the emergency medicine training program. She is working closely with Professor Gian Franco Gensini, dean of the University of Florence Medical School, she said, “to develop a program that incorporates Harvard Medical School’s principles of emergency medicine and quality management into Italy’s existing educational and training programs.”

Change, and some challenges along the way
Introducing this specialty into the mainstream of the Tuscan hospital system presents some challenges, both cultural and practical. For one, the notion of emergency medicine as it is understood in the United States does not resonate with many of Italy’s physicians. “I don’t think that many of the physicians here have a very good idea of what emergency medicine is,” said Ban. “We are working with doctors who are very talented on the clinical side, but the emergency medical system here is tremendously cumbersome.” He explained that the current system involves the interaction of multiple doctors from multiple specialties, rather than an emergency medicine specialist who makes the initial diagnosis of patients after they enter the hospital and then moves their care forward accordingly.

Dr. Richard Wolfe
Dr. Richard Wolfe of BIDMC-EM says that
emergency medicine “gratifies people who want to see that they’re making an impact immediately.”

Instituting this training, according to Dr. Richard Wolfe, BIDMC’s Chief of Emergency Medicine, will require physicians to adapt to a faster pace of patient care. “Of all the specific skills required of an emergency physician, the real key is speed, the ability to rapidly diagnose with minimal facts in the shortest possible time for the smallest possible cost,” he said. With the clinical skills largely in place, Italian doctors will have to develop their multitasking capabilities. “It’s the difference between playing a two-hour game of chess and playing ‘blitz chess,’ with games limited to five minutes against twenty opponents at once.”

Ban expects that those speedy chess players will emerge in the group of 24 as their training proceeds. “There is a certain type of person that is best suited to be an emergency physician. You can have the diagnostic skills, the dexterity, and the ability to multitask, but without the training to bring those qualities together and become truly poised under pressure, it’s difficult to deliver the highest quality emergency care possible.”

The overarching goal of this new training program is enhanced quality and more efficient systems for patient care. “The government decree does mean significant quality of life changes for the physicians,” said Wolfe, “including the number of patients they see, working different hours, and being challenged to provide immediate care to patients, and deciding which patients require that care.” He goes on to point out that accountability will increase for these doctors—and increased responsibility means increased pressure. “But what I’m banking on is that ultimately physicians who are interested in emergency medicine will practice out of professional pride. That means a lot.”

Wolfe credits Ban and his tireless efforts with much of the progress made so far. “Kevin is a large reason why this project will succeed. He has a great blend of enthusiasm, vision, and interpersonal skills. ”

 

Copyright 2003-2004 Harvard Medical International   •   http://hmiworld.org/

 

 

 

 

Emergency medicine in the U.S.: A brief history
As a specialized area of medical care, emergency medicine (EM) is relatively young, having emerged in the United States in the late 1950s and early 1960s with the realization that the lessons learned on the battlefield in Korea and Vietnam could be applied on the “home front” in hospitals. The techniques of rapid diagnosis and treatment that were designed to minimize casualties of war represent the foundation of the emergency care that many people today take for granted.

In the ten years between 1954 and 1964, the number of emergency hospital visits in the United States tripled. Then in 1966, a landmark report entitled Accidental Death and Disability, The Neglected Disease of Modern Society (prepared by the Committee on Trauma and Committee on Shock, Division of Medical Sciences, National Academy of Sciences, National Research Council), known simply as “the White Paper,” pointed out the deficiencies in the emergency medical care being offered at that time. One definitive excerpt: “Expert consultants returning from both Korea and Vietnam have publicly asserted that, if seriously wounded, their chances for survival would be better in the zone of combat than on the average city street.”

With a national crisis identified, the onus fell on individuals within the medical profession to address the issue. In 1968, a group of eight physicians formed the American College of Emergency Physicians (ACEP) with the goal of improving emergency care through education, structure, and standardization. A year later, 128 physicians attended the first Scientific Assembly devoted to emergency care, and in 1970 the first emergency medicine residency was started at the University of Cincinnati (Ohio). From that point it was merely a matter of time before the American Board of Emergency Medicine (ABEM) was formed, in 1976, and in 1980 the first Board-certified emergency physicians received their credentials. Today there are 127 emergency medicine residency programs in the United States.