What is Emergency Medicine?
Emergency Medicine (EM) is a distinct specialty that focuses on the initial evaluation, diagnosis, and stabilization of patients with acute illnesses or injuries. In addition, the EM physician initiates treatment, involves consultants, makes disposition decisions and appropriate follow-up arrangements for patients discharged from the emergency department (ED). Emergency Medicine became the 23rd recognized specialty in 1979. There are at least seven areas of specialized expertise separating the EM specialist from other disciplines:
- EMS systems design and supervision
- Disaster management / Mass Gathering
- Environmental emergencies
- Acute Pain Management
- Wound Care
The IUSM Emergency Medicine Residency
- Established in 1976 at Methodist Hospital of Indiana
- Became a part of The IU School of Medicine in 1999
- Expanded to a two campus system in 2000/2001
- R 1-3 Format: 18 residents per year
- Two campus system, 3 ED's (total of 225,000 visits/year)
- Combined program in Pediatrics-Emergency Medicine: - 2 residents per year. The oldest in the nation.
- "Full ongoing accreditation" status by the Residency Review Committee for the past 5 site surveys.
- "Full ongoing accreditation" status granted in the year 2011 for 5 full years.
The Indiana University School of Medicine Emergency Medicine Residency is dedicated to providing an excellent educational environment which prepares our graduates to enter the career pathway of their choice e.g. clinical, academic, fellowship, administrative, as well as pass the ABEM Certification Examination on the first attempt.The Emergency Medicine Residency started in 1976 and until 2000 was exclusively housed at the Methodist campus. Thus Emergency Medicine is well established at Methodist, with the same group providing care since 1970. Our practice setting is non-confrontational, and members of the medical staff treat emergency physicians with respect and collegiality.
With the creation of Clarian Health Partners and the Academic Department of Emergency Medicine, our residency has an unparalleled opportunity for further growth and development. Since July of 2000 we have added our second EM training site at Wishard Memorial Hospital (on the IUSM campus, only 1.5 miles away from Methodist). The ED there serves as the public health facility for the citizens of Marion County.
Wishard is a Level 1 ACS accredited trauma center for both adult and pediatric patients, houses the regional burn center, and the over 100,000 annual ED visits complement nicely the patient population encountered at the Methodist ED. Our faculty expanded from 21 (2000) to 44 (2008), and our residency complement has expanded from 43 to 61 (by 2002). Honestly, we are hard pressed to find any patient population or pathology that is not represented in our patient populations at Wishard and Methodist (all 200,000 of them!).
While Methodist is the 5th largest hospital in the nation in terms of annual admissions (144 adult and pediatric ICU beds - not including NICU) it offers the "best of all worlds" for a training environment. It serves as the major state referral centers for medical and trauma patients. The ED at Methodist is integrated with patients of all ages cared for during every shift. The private teaching hospital adds an environment of respect and camaraderie without hostile "turf issues," thereby allowing the resident to concentrate on education and training.
In July 2009 we added the Emergency Department at Riley Hospital for Children as a permanent training site. Located 1 block from Wishard, this is Indiana’s only dedicated full service pediatric hospital. The ED has the highest admission percentage of any Pediatric ED in the nation, assuring plenty of opportunities to interact with very ill and injured children (it is a Level 1 Trauma Center and houses the Pediatric Burn Unit). EM residents will rotate at the Riley ED during their R2 and R3 year. The Academic Department of EM provides administrative oversight for the Riley ED.
The residency relies heavily on resident involvement in its governance and evolution (in fact, we expect every resident to take an active role in decision making in all aspects of our residency, including such things as Chief Resident selection and development of our match list). We constantly ask ourselves: "How can we do this better?" and "What further opportunities exist?" Collegiality is emphasized not only amongst the residents but with the faculty as well. Don't let our large size worry you that we don't hold a tightly knit residency as one of our premier values! In addition to preparing excellent practitioners of emergency medicine, our curriculum emphasizes involvement in and understanding of the societal, political, and economic forces that affect our patients and our specialty (see section about EM advocacy). Our Academic Department is intimately involved in virtually every EM venue in our state. As a resident, you'll not have a problem finding a fascinating interest area with which to become involved…your challenge instead will be selecting one from our huge menu of opportunities.
The Indiana University School of Medicine - Emergency Medicine Residency is dedicated to providing an excellent educational environment which prepares our graduates to enter the career pathway of their choice (e.g. clinical, academic, fellowship, administrative), as well as pass the ABEM Certification Examination on the first attempt. We believe that the "gold standard" for training is to assure that any of our graduates could successfully practice in a busy solo-coverage community ED…the most challenging practice environment in medicine. In this setting, the physician must possess the cognitive and technical skill set to care for any patient for at least 45 minutes without the assistance of other consultants, or even without the availability of diagnostic tests that are often taken for granted in large teaching hospitals. While almost 30% of our grads go on to further training and academic careers, we assure that all of our grads can meet this "gold standard".
Ours is not a good "fit" for residents who would be uncomfortable with our mantras :"How can we do this better?" and "What further opportunities exist?". We apply this same philosophy to each individual (faculty and resident), and strive to push residents (in a positive, challenging fashion) out of their comfort zones in order for them to truly understand how good of an EM physician they can be. Our program is also not a good "fit" for residents who aren't "we" people. Our residency is a family, and each of us steps forward for others. As a resident here, you will periodically inconvenience yourself for peers. Likewise, you can be assured that your peers will do the same for you in your times of need. Finally, our program rewards those who are active participants. Our unique governance structure allows every resident meaningful involvement and leadership opportunities with the goal of making a lasting positive contribution to THEIR residency.
Our residency encompasses two high volume, high acuity general Emergency Departments that manage patients of all ages with every type of medical condition and a moderate volume pediatric Emergency Department. The combined Wishard/Methodist/Riley ED census of over 230,000 patients has a wide socioeconomic variety, with opportunities to care for celebrities and homeless patients alike. All patients are under the administrative control of EM physicians. Almost all patients are directly staffed with our faculty rather than with an upper level EM resident. We believe that you maximize learning opportunities by interacting with an experienced faculty member rather than a more senior level EM resident who may only have experienced 6 more EM rotations. During a "typical" shift at the Methodist ED you will manage a pediatric patient with a fever, repair a laceration or relocate a dislocated joint, evaluate a pregnant patient with vaginal bleeding, care for a victim of domestic violence, evaluate a middle age homeless man with chest pain and care for an elderly nursing home patient presenting after a fall. At the Wishard facility you will care for a victim with multiple gunshot wounds, a young man with a respiratory arrest associated with IV drug abuse, an elderly woman with pneumonia, a diabetic suffering complications associated with poor medical control and an incarcerated patient with blunt trauma from a baseball bat. During your Riley ED shifts you will interact with normal children with acute illnesses and injuries, as well as a large population of chronically ill children with exacurbations of their underlying process, or an acute process that complicates this problem. In essense, this is exposure to the "sickest of the sick".
Another unique aspect of our residency is the wide exposure to a variety of "provider / consultants". At the Wishard site the more traditional housestaff hierarchy serves as the initial resources for admissions and consultations. At the Methodist facility, one third of the admissions are handled by the traditional housestaff teams, while two-thirds of consultations and admissions occur directly with the patient's attending physician or a designated staff hospitalist team. Because the residents must communicate with a variety of providers (HMO, PPO, hospitalists, private solo practice, group practice, public clinics and housestaff teams), they develop a critical skill set required to interact with "real world" staff physicians. This interaction promotes an understanding of the "nuances" of community practice as well as providing an educational opportunity at the subspeciality attending level.
All 3 facilities use advanced computer technology, including a completely computerized triage and tracking system, immediate access to discharge, operative and consultation reports, laboratory data and ED records (directly entered through our dictations), and digitized radiology. Wishard & Methodist facilities have "Fast Track" areas staffed by Nurse Practitioners as we believe resident involvement in such areas provides limited educational dividends ("service over education"). We also operate a newly rennovated 19 bed Intensive Diagnostic and Treatment Unit under the operative control of the Methodist ED. Here we manage adult and pediatric patients for up to 23 hours, and there is an additional psychaitric intake area. Examples of conditions that may be managed here include chest pain (dobutamine stress echocardiograms), poisonings and intoxications, asthma/COPD, minor head trauma, dehydration, and selected abdominal pain. Both facilities offer comprehensive care for victims of sexual assault through our "Center of Hope" network.
In addition to the general EMS (out of hospital care) requirements, our program affords several unique additional EMS opportunities. Residents desiring additional experiences may become associate medical directors for one of the many systems for which we provide medical oversight. Starting in the EMR2 year, residents may pair with an EMT-P as a team, responding to, evaluating and transporting patients. In this system, the resident serves as the medical provider in the ambulance. These shifts are incorporated into the regular ED shift schedule for participants. We have numerous opportunities for involvement in the planning and provision of care for the many mass gathering events in the Metro area (see below). While we have had a historic involvement in the Life Line helicopter transportation service, the proliferation of competing services and poor safety profile of medical helicopters throughout the US makes the decision to fly one that should not be taken lightly. Until all transport systems meet recommended safety standards, we have suspended resident involvement with air ambulances.
Our Toxicology experience is truly exceptional. We house the Indiana Poison Center, the only one in the entire state and one of the overall busiest in the nation. Our 4 board certified medical Toxicologists supervise the Medical Toxicology Fellowship as well as both an inpatient and outpatient service with primary (not simply consulting) patient care responsibilities. Inpatient adult and pediatric cases are managed primarily by the Toxicology service.
In the area of Mass Gathering Medicine, we have a wide variety of opportunities including planning and providing care at the Indianapolis Motor Speedway (Indianapolis 500 , Nascar Brickyard 400 and North America Formula One races), the Indianapolis Mini-Marathon, events in the Lucas Oil Stadium and Murat Theater, several PGA/WPGA tournaments, the National Rowing championships, numerous NCAA events, and the 2012 Super Bowl. Clarian was the medical sponsor for the World Police and Fire Games (9,000 athletes from over 40 nations) as well.
Outside of the ED, many of our off-service rotations are directly under the supervision of a faculty member rather than a traditional tiered housestaff team. In such a system, increased levels of responsibility and access to procedures is possible, even at R1 levels of responsibility. Ongoing pediatric experience occurs in a number of these rotations such as Orthopedics, Neurosurgery, and trauma surgery. Pediatrics is a major focus of our residency. Since 1991 we have sponsored the oldest combined EM-Pediatrics combined residency in the nation. Seven of our faculty are double boarded in EM and Pediatrics, and one by ABEM Pediatric EM subspecailty certification. Our didactic schedule focuses almost one third of our time on Pediatric emergency care issues.
In 2009 we introduced two "Tracks" into our curriculum. (The Academic Track and the Scholars in Advocacy Track). Each affords additional "value added" opportunities for participants. We have since added an Out-of Hospital medicine Track.
Our curriculum remains innovative and undergoes continuous evolution with an eye to future graduate needs. We continuously seek opportunities for improvement, and our residents are integral in the continuous improvement process.
Our record for graduates is excellent, with a 99% pass rate on both parts of the ABEM certification examination for all classes since 1984. Our graduates have had uniform success accessing the career pathway of their choice, be it academic, fellowship, or community practice. Because our residency has been in existence since 1976, we also have a nation-wide "network" that assists our graduates in the job market. Many of the best jobs in EM are available only through word of mouth.
We believe that the most challenging job an EM physician will face is that of the busy single coverage community ED. In such a setting, the EM physician is the only physician in the hospital, and must manage all problems without the assistance of second opinions, extra hands or other physicians for at least 30-45 minutes. We prepare all of our graduates to meet this standard so that they can comfortably step into any ED in the nation and have a rewarding practice.
Finally, although the 3 years of post-graduate study in EM is challenging and busy, we have not lost sight of the need for your personal as well as professional development during this time. We believe that optimal learning occurs not in a stiff, hierarchical system, but instead in one that values collegiality and camaraderie. We view our residents as our future peers, and place emphasis on maintaining non-abusive work environments and maximizing resident input into their education process. Our resident class each year is comprised of graduates from schools in an average of nine different states. Their selection of our Midwest program was obviously not for Indiana's oceanfront or ski resorts. We believe their decision rests with the truly unsurpassed training opportunities available here.
The underlying philosophy of the residency is optimal learning comes first and foremost by evaluating and treating patients. This clinical experience is strongly supplemented by formalized didactics and case-directed readings. The IUSOM Emergency Medicine Residency realizes these goals and philosophy through a comprehensive mixture of clinical exposure (both in and out of the ED) and didactic lectures. Training is provided in the administration of emergency departments and Emergency Medical Services systems. Teaching skills are developed through the presentation of in-services and didactic lectures.
- Recognize, evaluate, and treat all patients with life or limb threatening conditions presenting to the ED. This includes the ability to simultaneously manage multiple patients as well as direct or supervise resuscitation efforts
- Make a timely and appropriate disposition for all patients presenting to the ED. This includes the ability to effectively interact with the patients, family members, and consulting or private physicians.
- Manage and direct mass casualty situations and participate in disaster planning.
- Develop teaching skills suitable to disseminate information to all levels of care providers, particularly prehospital personnel.
- Interact effectively with prehospital care providers and function as a Base Station physician.
- Effectively perform administrative tasks necessary to manage an emergency medicine service including scheduling, risk management, continuous quality improvement, and the handling of patient complaints.
- Pass Part I (written) and Part II (oral) Emergency Medicine Boards on the first attempt.
- Enter the career pathway of your choice clinical, administrative, fellowship and sub- specialization, academic (tenured or clinical track), or research.
- Develop competence in evaluating the medical literature and understanding research methodology.
- Develop a system for life-long learning to meet your professional goals after residency.
We have created a work environment designed to create opportunities for you to learn and develop your skills as an EM specialist. YOU MUST BE THE DISCIPLINED FORCE NEEDED TO TAKE ADVANTAGE OF THESE OPPORTUNITIES! Residency is not easy, for there is an incredible amount of information and experience that must be gained in preparation for a successful practice, passing the ABEM certification examination and assuring longevity in your career. We expect you to have the intellectual and emotional maturity that will allow you to focus on your education as the major work priority over the next three years.
We practice EM as a team. Likewise, our residency is constructed to build on teamwork and camaraderie. Many of the innovations in the residency
developed through the contributions and work of those who proceeded you. We anticipate that you too will adopt these attributes and work with us in the ongoing development of your residency. Let us always ask, "How can we do this better?" and "What opportunities are there that we could take further advantage of?" You will be challenged as you arrive with the question "What will your legacy of contributions to your residency be?"
A residency program is a transitional period to the clinical practice and academic pursuit of Emergency Medicine. You truly have unlimited opportunities available to you in our residency. What you accomplish depends largely on your aggressiveness in pursuing the opportunities that have been created for you! Our goal is to press you to become THE BEST EM PHYSICIAN YOU CAN POSSIBLY BECOME. The Directors and Faculty will assist you in achieving this goal by helping you define personal goals, setting standards and deadlines, providing you feedback on your performance, and serving as role models. Only in this way can you gain the rewards you deserve for three years of hard work and dedication. Ultimately, you have the responsibility for your education as a specialist in Emergency Medicine. Our charge is to assure the existence of an environment conducive to that end.
Your time in the residency will be governed by an HONOR CODE. Physicians must not be "selectively dishonest". Ethical conduct in one's interaction with peers, employees, and residency requirements reflects the tremendous moral and ethical responsibilities inherent in our caring for patients. It resides as one of the cornerstones of professionalism. Lying, cheating, stealing and patient abandonment are incompatible with a successful practice of EM.
Your input into the residency is not only desirable, but also critical to its ongoing growth and development. You may anticipate that the program from which you will graduate in three years will be different from the one you enter today. This will be a reflection of changes enacted with your input and participation. This is YOUR PROGRAM; you own 49% of the shares. It is encouraged that you aggressively participate in refining and supporting the residency.
In one attempt to formalize the critical role residents play in the management of your residency, we have established a resident committee structure. A resident chairs each committee, and the membership selected on a volunteer basis from all 3-year levels. A faculty member serves as a liaison. The agenda is developed conjointly by the committee and Program Directors. Historically, the Education Committee has enacted all formal proposals presented to it by the committees.
Our residents participate in all important decisions in the residency. In fact, participation is expected. This includes hiring of new faculty, the interview process, the rank list, and selection of Chief Residents. Resident evaluation of their educational experiences is likewise critical to the ongoing development of our residency.
Involvement in the residency should be paralleled by participation in the national organizations that represent Emergency Medicine. These include:
- American College of Emergency Physicians (ACEP, the "political" branch of the specialty
- Emergency Medicine Residents' Association (EMRA)
- Society of Academic Emergency Medicine (SAEM, The "academic" organization of the specialty
- American Academy of Emergency Medicine (AAEM, Membership is limited to ABEM certified EM Physicians, resident category is available.)
Those with special interests should consider the National Association of EMS Physicians or the Wilderness Medical Society.
The Indiana Chapter of ACEP reserves an active position on the Board of Directors for one of our residents. In addition, one resident should be active as our representative to EMRA.
You are expected to subscribe to the Annals of Emergency Medicine sponsored by ACEP (the subscription is included in your ACEP/EMRA dues) and Academic Emergency Medicine sponsored by SAEM (covered by your SAEM dues). Over the next three years selected books will be purchased for you. Finally, you are encouraged to purchase a personal computer (PC) for word processing, literature searches, and research. Ample resources and training opportunities exist in the program to allow you to become proficient with a PC. It is important to maintain your involvement with the organizations supporting Emergency Medicine.