A Young Emergency Physician Appreciates the History of U.S. Emergency Medicine Through the Lens of China’s ERs

I’m a young emergency physician, part of the “new breed” that’s always known emergency physicians to be residency-trained and emergency medicine (EM) as a well-respected field. Being a leader in the American Academy of Emergency Medicine, I often hear of our organization’s leaders speak about the struggles they had in establishing our specialty, but I didn’t have a sense of what they actually went through. Why is that they so dislike the term “emergency room” and cringe at the reference to “ER doctors”?

It took a visit to China for me to even begin to understand the reasons. In August-September 2012, I traveled back to the country of my birth to study the current state of medical education here. My trip traversed 9 provinces and involved visits to 14 medical schools and over 50 hospitals.

Being an emergency physician who is interested in healthcare systems, I was particularly curious to visit the Emergency Departments there (we prefer this term and the abbreviation “ED”s to ERs for reasons I’ll speak about later). What I found is quite far from the EDs I know. In fact, everywhere I visited, from rural provincial hospitals in Inner Mongolia to major inner-city teaching hospitals in Beijing, had an emergency ROOM. That’s because patients were literally seen in a giant room, with beds pushed against walls and (if they are lucky) a curtain to divide the rooms. Extra patients were lined up along hallways, often six-deep.

Many places had triage to service, meaning that patients were triaged to a specific area to be seen by specialists who came through the ER. So internists would see patients designated as having medical problems, surgeons would see patients thought to have surgical problems, etc. If the patient turned out to a different problem than was initially decided, a long discussion would take place before the patient was transferred to the correct part of the ER.

Since China is a densely populated country, many hospitals had serious issues with overcrowding. Not surprisingly, the biggest problem seems to be with patients waiting for a hospital bed—basically, boarding.

“Do you often see patients waiting for a bed for 24 hours?” I asked a doctor in a major Beijing hospital.

“24 hours? We are lucky if there’s a bed in 72 hours!” He went on to describe the difficulties he had with admitting an elderly woman with heart failure, diabetes, kidney problems, and liver cancer who came in with difficulty breathing. The cardiologists refused the patient, saying the problem was the kidney. The nephrologists declined, saying diabetes or cancer was the underlying problem. Oncology and endocrine stated the chief complaint was not mainly their issue. General internal medicine said the patient was too complicated. As a result, the patient stayed in the ED for the entirety of her care—a total of 30 days.

The emergency physicians I met attributed the problem of boarding to the lack of respect for the specialty. Though EM is a specialty in China, and there are EM residency programs in some cities, it is considered to be a specialty of last resort—for those physicians cannot make it in other fields. Most EDs are divisions that exist only under the auspices of “real” departments such as surgery and medicine. Attendings working in the ED are scorned by others, and fights over airway, chest tubes, and other procedures are frequent occurrences.

Hopefully, my fellow young American physicians are wondering what kind of backwards environment I’m describing, but many reading this column are probably thinking that this description is not too far from the reality they knew. Indeed, the road to becoming a specialty involves predictable stages. My generation takes it for granted that we are part of excellent training programs and will be specialists in a well-respected medical field. But it wasn’t long ago that our predecessors fought the same battles that China faces now, of specialty recognition, admission privileges, scope of practice, etc.

We young emergency physicians need to thank those who came before us for making our specialty what it is and paving the way for us. For creating the emergency DEPARTMENT (rather than the ER) staffed by emergency physicians (rather than ER docs). For ensuring safer and better care for our patients.

We must also recognize that while many problems have been resolved, many remain. Overcrowding and boarding continue to be problems in EDs across the U.S. There are continuing challenges to our scope of practice, and other specialties still question our abilities. Vocal groups still insist that there are other ways to become “certified” emergency physicians through alternative boards. The corporate practice of medicine remains a real issue for practicing physicians.

It’s imperative for young emergency physicians like myself to continue to find value for our specialty. China’s EM leaders have found creative solutions around their overcrowding and scope of practice by starting “E-ICUs” (emergency ICUs) and transitional care units (transition from E-ICU to home) and staffing “emergency inpatient” and observation units. As we look to the future of EM, we should be aware of our history, work to overcome ongoing problems, and continue to advance our specialty and improve healthcare, in the U.S. and internationally.

This article was initially published in AAEM’s Common Sense magazine. I welcome your comments!