CrystalBallsmAs I was perusing through a recent Academic Medicine journal, I came across this interesting perspective piece on Emergency Medicine, written by national leaders in our specialty.

This article essentially states that how the nation addresses ED crowding will define the future of EM. Currently, Emergency Departments are at a breaking point where overwhelming demands are commonly placed on under-resourced practices.

Ten years ago, a SAEM task force accurately forecasted the following about the specialty of EM:

  • The increasing importance and growth of electronic information systems
  • A larger ED volume with greater numbers of elder patients
  • Growth of home care, telemedicine, and EM research

The task force, however, did not predict the phenomenon of having ED boarders (patients staying in the ED for many hours awaiting an inpatient bed). Also their prediction that there would be greater health insurance coverage has not yet come true.

This article posits three different scenarios for the future of EM, from a pessimistic, optimistic, and realistic perspective:

Pessimistic – “It’s all about the money.”

For ED’s where uncompensated care is common, the financial stressors will be too much. These ED’s will close down. To save on personnel costs, emergency physician salaries will drop. Also, many will be replaced by mid-level providers (NPs, PAs) in many rural and some urban areas. Patients seeking acute medical care may essentially just get triaged in the ED to other places for further care. This decreases the likelihood that medical students will want to pursue a career in EM.

Optimistic – “It’s all about the quality of care.”

More important than the excessive costs of health care are patient outcomes and the quality of care. Hospitals and/or politicians will solve the ED boarding problem and focus on optimizing the ED’s ability to address key time-sensitive disease processes (acute MI, sepsis, stroke, trauma, etc). The ED will become the central diagnostic and treatment hub for all out-of-hospital care. The Internet will play a major role in this, including the use of telemedicine technologies. EM will play an even more critical role in health care than it already is.

Realistic – “It’s about the money AND quality of care.”

Our specialty of EM will have to demonstrate that improving quality of care ultimately results in long-term cost savings. ED observation units will be more common, as a means to reduce inpatient costs. Electronic medical records and health information systems will play a critical role in optimizing care and minimizing costs. The continued incorporation of physician extenders (NPs, PAs) will reduce overall physician workforce requirements. And lastly, emergency physicians may also find themselves “outsourced” in a “boutique medicine” fashion — that is — practicing EM in workplaces, malls, and hotels.

Oooh. I want to work at Google, if they have a spot.

Sklar DP, Handel DA, Hoekstra J, Baren JM, Zink B, Hedges JR. The future of Emergency Medicine: an evolutionary perspective. Acad Med 2010; 85:490-5.


Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD