348 ACADEMIC EMERGENCY MEDICINE APR 1998 VOL 5/NO 4

Definition of Emergency Medicine

Sandra M. Schneider. MD, Glenn C. Hamilton, MD, Peter Moyer; MD,
J. Stephen Stapczynski, MD

I ABSTRACT
.....................................................................................................................................................
This SAEM position paper clarifies the role of emergency medicine in health care delivery. It builds upon the
working definition of emergency medicine developed by the American College of Emergency Physicians in
1994 by describing the health care role of emergency physicians (EPs). EPs are first-contact providers who
care for all patients regardless of age, gender, time of presentation, or ability to pay. They remain the only
continuously accessible specialty for patients seeking help and solace in the health care system. They are an
essential link in the health care continuum between primary care physicians, specialists, the out-of-hospital
system, the patient, inpatient services, and communication services. The EP’s role is in organizing and mon-
itoring the emergency care delivery system. Part of this role is to better align the health care provider training
and ability with the specific medical needs of a patient. The emergency health care system remains the essential
medical safety net for all individuals needing care in this country.
Key words: emergency medicine; medical specialty.
Acad. Emerg. Med. 1998; 5:348-351.

I This position paper clarifies the availability. EM exists at the interface of evaluating, managing, treating and
role of emergency medicine (EM) in of out-of-hospital and in-hospital preventing unexpected illness and in-
health care delivery. As a new spe- care. It serves an advocate role for jury.
cialty, the perception of the spe- both patients and physicians. This “Anyone may unexpectedly re-
cialist’s scope of practice and stan- role must be understood by the pop- quire medical care at any time. Emer-
dards may be based on outdated ulations we serve-the public, the gency medical care must therefore be
personal experience or influenced by provider, and the health care insurer. available 24 hours a day as an essen-
the media. EM represents a specialty tial component of a health care deliv-
that bridges between primary care DEFINITION ery system.
and specialist services, offering ele- “Emergency Medicine encompasses
ments of both while maintaining a “Emergency Medicine is the medical a unique body of knowledge, outlined
unique position of ready access and specialty with the principal mission in the Core Content for Emergency
...............................................................................................................
Medicine.’ Emergency physicians
provide rapid assessment and treat-
ment of any patient with a medical
From the University of Rochester Medical Center, Rochester; N1: Department of Emergency
Medicine (SMS);Wright State University, Dayton, OH, Department of Emergency Medicine emergency. In addition, they are re-
(CCH); Boston University, Boston, MA, Department of Emergency Medicine (PM);and sponsible for the initial assessment
University of Kentucky Medical Center, Lexington. KX Department of Emergency Medicine and care of any medical condition
(JSS). that a patient believes requires urgent
Received: November 7. 1997; accepted: November 9, 1997. attention, and they provide medical
This paper was commissioned by the SAEM Boa& of Directors. The authors are members of care for individuals who lack access
the SAEM Subspecialty Task Force. to other avenues of care.
“The specialty of Emergency
AaZressfor correspondence and reprints: Sandra M. Schneider, MD, Strong Memorial Hospital,
Department of Emergency Medicine, Box 321, 601 Elmwood Avenue, Box 4-9200. Rochestes NY Medicine is practiced in a variety of
14642. Fax: 716473-3516; e-mail: sschneid@ed.urmc.rochestexedu hospital and nonhospital settings.
Definition of Emergency Medicine, Schneider ef al.
Emergency physicians have a role as
both direct providers and coordinators
of patient care. As a result, they pos-
sess a deep understanding of the lo-
gistics of medical care. They are
uniquely positioned to play a pivotal
role in the planning, developing, im-
plementing, and evaluating effective
and efficient health care systems.
“Emergency Medicine exists to
provide access for all to unplanned
but needed health care. It is America’s
health care safety net.”*
Emergency medicine also pro-
vides early warning, surveillance, and
linkages to primary care and preven-
tive services, as well as health policy
advocacy for the nation’s public
health problem^.^
Emergency physicians (EPs) are
first-contact providers. They care for
a patient population undifferentiated
by age or disease process. They pro-
vide rapid treatment and stabilization
of true emergencies, as well as rapid
differentiation between emergent and
nonemergent conditions over the
spectrum of disease processes. Their
care extends to out-of-hospital assess-
ment, treatment, and transport of pa-
tients into emergency facilities by
virtue of their management and su-
pervision of emergency medical ser-
vices (EMS) systems.
Patients are often self-referred,
perceiving a need for acute medical
treatment, either because of its ur-
gency or perceived urgency, or be-
cause of inability to access other
medical care. For those patients, EPs
provide appropriate treatment and,
importantly, access to the proper
medical provider or facility when
available. Another large group of pa-
tients are referred by primary care
providers for evaluation and appro-
priate dispositions, particularly during
after hours. For these patients, the EP
becomes a consultant for the primary
care physician. The relationship be-
tween the primary care physician and
the patient is maintained.
Emergency medicine is an essen-
tial link in the health care continuum.
EPs direct ground and air ambulance
349
systems, coordinate the care of pa- used to categorize care in the ED. The
tients referred by community provid- 3 tiers are seen in the ED because of
ers, and initiate inpatient and outpa- patient perception of the seriousness
tient treatment. EDs are effective sites of the problem, patient preference, the
for preventive care (immunizations, out-of-hospital delivery system, or the
detection and intervention for sub- lack of timely access to another care
stance abuse and violence). Emer- giver.
gency personnel play key roles in dis-
aster management and poison centers. Nonurgent. This represents up to
Medical student and graduate 40% of care given in the ED. It is
medical trainees learn the skills of typically defined as “primary care,”
rapid patient assessmenthtabilization the type of problem managed by a
and differential diagnosis from aca- primary care physician in the office
demic EPs. In the unique atmosphere setting. This level of care is managed
of an ED, trainees learn first-contact according to the available resources,
skills for undifferentiated illness or skills, and the mission of the institu-
injury, which can be used in inpatient tion. Many of these patients can be
or outpatient care. Academic EPs are cared for by physician assistants or
committed to the expansion of our nurse clinicians, with appropriate and
knowledge base through directed re- available physician backup and su-
search. EM research encompasses ba- pervision. Selected patients, e.g., den-
sic science and clinical investigation tal, are referred to specialty clinics af-
of acute injury or disease, health ser- ter appropriate assessment.
vices delivery, and outcomes re- Urgent. These represent about
search. 40% of emergency care needs. Most
of these patients present for assess-
PROVIDERS OF ment of undifferentiated illness or in-
EMERGENCY CARE jury, often not initially suggestive of
a life-threatening process, e.g., ab-
The urgency or emergency of a pre- dominal pain, headache, laceration, or
senting complaint is often first deter- straidsprain. The important skill in
mined by the health care consumer- caring for these patients is to rapidly
the patient who comes or the person differentiate them from those with
who brings another to the ED. In more emergent needs. This is a
other circumstances, the presenting learned skill gained from specific
concern is first addressed by individ- training in EM. Once the patient is
uals who provide out-of-hospital care appropriately assessed and stabilized,
via ground and air ambulances. These technical skills, e.g.. suturing of un-
out-of-hospital personnel are usually complicated lacerations, are per-
under the medical direction of an EP. formed by EPs or specifically trained
The first contact with nursing staff providers.
and the EP during the screening ex- Emergent. These patients make
amination in the ED confirms or mod- up about 20% of emergency visits.
ifies this initial determination. EPs are They may present in extremis
specifically trained in the rapid as- (shock, cardiac arrest, or multiple
sessment and triage of all patient trauma), or may evolve to potential
presentations regardless of patient age life-threatening problems during their
or gender. The EP’s role is to organize evaluation (early sepsis, dissecting
and manage the emergency care sys- aortic aneurysm, or diabetic ketoaci-
tem based in the ED. This includes dosis). They can masquerade as ur-
selecting and training individuals to gent or, at times, nonurgent patients.
deliver specific levels of care, and co- Rapid differentiation of their need for
ordinating these levels to achieve a care level and appropriate manage-
seamless interface between them. ment is essential. These patients re-
Commonly a 3-tiered system is quire care by physicians trained in
350
EM, combined with appropriate con-
sultant referral and follow-up.
The EP is uniquely positioned to
manage all 3 levels of care, and to
categorize the undifferentiated patient
into the appropriate level of care.
While other training may include
some aspects of emergency care of
related illnesses or injury, the physi-
cians trained in EM uniquely master
all of this knowledge base. While pro-
viding and supervising nonurgent
care, EPs provide expertise in effi-
ciency and the detection of unsus-
pected serious conditions. Because of
the nature of our practice, we provide
such care with low marginal costs.
Lifelong learning is a part of the
emergency care experience. All pro-
viders must commit to their patients’
needs and a career path dedicated to
emergency care. The educational con-
tent for the training of an EP is well
established by the Special Require-
ments for Emergency Medicine and
the Core Content of Emergency Med-
icine. There is some overlap in the
training of an EP when compared
with that of physicians in fields of
family practice, internal medicine,
and pediatrics. However, only the ‘EP
receives training that emphasizes
managing and triaging undifferen-
tiated presenting complaints in the
ED.
The initial assessments of clinical
competency of personnel within
emergency medical care delivery sys-
tems (fire, police, out-of-hospital pro-
viders, nurses, nurse practitioners,
physician assistants, etc.) must be the
responsibility of trained EPs. They
are specifically oriented toward the
time-dependent, triage-based decision
making in the midst of uncertainty,
and breadth of age and disease that
help define the nature of this complex
specialty.
PRIMARY CARE VS
SPECIALIST
The discussion about the benefits and
future of primary care has been dom-
ACADEMIC EMERGENCY MEDICINE
inated by the distinction between pri-
mary care physicians and specialty
physicians. This debate assumes that
there is a clear distinction between
primary care physicians and special-
ists. This oversimplifies the variation
of physician training and clinical
practice. In considering the responsi-
bility for care of a diverse population
of patients who present themselves to
the ED, current “primary care” labels
are inaccurate.
The Council of Graduate Medical
Education (COGME) 3 report (1992)
identifies 6 characteristics of the pri-
mary care physician:
1. This physician evaluates patients
on first contact.
2. This physician evaluates patients
with undifferentiated symptoms.
3. This physician coordinates.further
evaluation and subsequent care.
4. This physician provides compre-
hensive care or supervises and
monitors care for all medical prob-
lems.
5. This physician provides longitu-
dinal care for the patient’s medical
problems.
6. This physician practices with re-
duced reliance on technology and
procedures.
Thus the ideal primary care physi-
cian would see any patient (both sexes,
all ages) for all medical problems at
any time, and be able to handle all
problems for the life of the patient.
Even “primary care”-designated phy-
sician groups fail to meet this require-
ment. Pediatricians do not see 75% of
the general population due solely to
age. Two-thirds of family medicine
physicians do not perform obstetric
care. Internists see few children or
obstetric cases. After-hours care by
many specialists may be inconsistent,
shared between a number of provid-
ers, or unavailable. Thus a clear dis-
tinction between primary care physi-
cians and specialists does not exist.
APR 1998 VOL 5/NO 4
Emergency physicians are uni-
que medical specialists. They provide
highly technical and sophisticated
care to the most emergent patients.
EPs are also primary care physicians
who evaluate patients on first contact,
assess undifferentiated symptoms and
signs, and provide medical care
coordination particularly for those
patients who require referral or ad-
mission to hospital. EPs are also gen-
eralists. While care often is brief, they
evaluate all ages and both sexes for
any and all presenting complaints. Al-
though they are often based in the
technology-rich setting of the hospi-
tal, they overwhelmingly rely on low
technology and limited ancillary tests.
Emergency physicians are an es-
sential hybrid of primary care, first
contact of undifferentiated care for all
ages, and specialty care, with exper-
tise in the initial management of crit-
ically ill patients. They coordinate
care at the interface between out-of-
hospital and hospital medicine, but do
not monitor or provide long-term
care.
THE ED AS A SAFETY NET
In a developed country such as the
United States, access to quality emer-
gency medical care is a community
expectation much as the fire and po-
lice departments. Emergency medical
personnel should be considered es-
sential. Access to emergency care
should be available even when it does
not pay for itself, in rural areas where ,
ED volumes may not be adequate to
underwrite emergency care, and in
any area where the payer mix cannot
cover cost.
Despite the efforts of primary care
proponents, access to health care in
the traditional office setting is often
difficult. The ED provides access to
health care for all. While primary care
sites will provide much of this care
during the day, the ED will continue
to be called upon to provide this care
during off hours. In rural and inner-
city communities without adequate
primary care access, the ED sees
Definition of Emergency Medicine, Schneider et al.
nonemergency patients during all
hours for large sections of the popu-
lation: the uninsured, homeless, sub-
stance abusers, victims of violence,
immigrants, and prisoners. Further,
the ED, through the Emergency Med-
ical Treatment and Active Labor Act
(EMTALA), is the only medical care
site obligated to see any and all pa-
tients who present. This act requires
all patients to have a medical assess-
ment (medical screening examina-
tion) regardless of a chief complaint
or ability to pay. Emergency services
will always be an essential compo-
nent of quality health care. Beyond
just providing access, EPs administer
immediate life-sustaining, sometimes
lifesaving treatments and, to those
with “lesser” emergencies, rapid com-
fort and treatment to decrease morbid-
ity. Initiating therapy on a Friday eve-
ning for a problem that “could wait
until Monday” decreases suffering
and lost wages.
THE ED IN MANAGED
CARE
In our cost-conscious environment,
many patients are directed away from
emergency care and EDs are being
held accountable for “unnecessary
visits.” EPs are cost-effective gener-
alists providing comprehensive, high-
quality care in a variety of settings to
people with a broad array of health-
related condition^.^ Emergency care
has been called “the most expensive
health care”; however, this percep-
tion is based on charges, and these are
reflective of the high fixed costs and
an existing illogical reimbursement
system for emergency care. The mar-
ginal cost of nonurgent patients in
fact does not exceed the cost of an
outpatient v i ~ i t . ~
Emergency physicians provide
important management of utilization
of health resources. The interface
with inpatient services is broad, in-
volving nearly all hospital services.
Through clinical observation in the
ED and rapid diagnostic testing,
costly admissions can be avoided.
EPs coordinate alternatives to inpa-
tient care and are valuable resources
in the development and evaluation of
outpatient and home services. As
such, EPs are advocates and exten-
sions of the primary care practitioner.
Managed care organizations will find
it prudent to work with EPs, as well
as primary care physicians, to create
alternatives to hospital admission and
align incentives accordingly.
Emergency physicians can prac-
tice preventive medicine to a popu-
lation often difficult to reach and at
high risk. Through prompt identifi-
cation of health and social risk fac-
tors, referral to early intervention and
preventive programs will control fu-
ture health care costs. On the other
hand, EPs will remain patient advo-
cates, defending medically and so-
cially appropriate admissions, if nec-
essary, over the protest of insurers.
CONCLUSION
Emergency physicians are first-con-
tact providers who care for all pa-
tients regardless of age, gender, time
of presentation, or ability to pay.
They remain the only continuously
accessible specialty for patients seek-
ing help and solace in the health care
351
system. They are an essential link in
the health care continuum between
primary care physicians, specialists,
the out-of-hospital system, the pa-
tient, inpatient services, and commu-
nication services.
The EP’s role is in organizing and
monitoring the emergency care deliv-
ery system. Part of this role is to bet-
ter align the health care provider
training and ability with the specific
medical needs of a patient. The emer-
gency health care system remains the
essential medical safety net for all in-
dividuals needing care in this country.
Emergency medicine exists to
serve 2 populations, the patient and
the physicians who will see that pa-
tient in consultation or follow-up. In
this role, EPs can serve as cost-effec-
tive providers with a specialist’s abil-
ity to care for the most seriously ill
and injured. Patient advocacy is the
fundamental principle of emergency
medical practice, and collaboration is
the primary goal of the specialty.
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