The emergency department where patients receive care today is dramatically different from the ER they would have visited before the 1970s. Back then, the emergency room was just that — one big room where patients came for care. There were no emergency medicine specialists. ERs were staffed by interns and residents who called attending physicians in various specialties when they needed help in treating a patient — a far cry from the sophisticated emergency departments of today.
The movement for a specialty in emergency medicine arose out of a trend in medicine toward specialization that started growing after World War II, according to David Wagner, MD, former chair of the College's Department of Emergency Medicine, who started one of the first emergency medicine residencies in the country at Drexel's predecessor school the Medical College of Pennsylvania. Wagner is widely recognized as one of the founding fathers of emergency medicine.
"As more doctors specialized, it became increasingly difficult for patients to find a general practitioner in the local neighborhood," Wagner explains. "Out of necessity, patients began going to the next level of care – the local hospital – and the entry point for service is the ER. Consequently, hospitals became inundated with patients arriving for care through emergency services. Emergency medicine was the first specialty that was patient driven and community centered."
STAGE 1: MOONLIGHTING
Initially, hospitals tried to handle the influx by sending an attending physician to work in the ER. At Woman's Medical College (MCP's predecessor), they began to handle the situation in the 1960s by hiring a physician to work in what was then a very primitive ER for eight hours during the daytime. They soon realized that they needed coverage in the evening as well. Wagner, who had joined WMC in 1965 as a full-time faculty member in the Department of Surgery, became the evening ER physician.
"The hospital offered me $5.63 an hour to work in the ER from 6 p.m. to 2 a.m., and they said I could keep what I earned in addition to my salary of $14,000 as a faculty member. So I jokingly tell people that I got into emergency medicine for the money," says Wagner. "I began working every other evening in the ER while at the same time fulfilling my responsibilities as a full-time pediatric surgeon and general surgeon."
Wagner became director of Emergency Services at Medical College of Pennsylvania, and went on in 1971 to establish the first emergency medicine internship and the second emergency medicine residency in the country (the first three-year residency nationwide).
A senior medical student, Pamela Bensen, MD, MCP '71, played a key role in these endeavors. In 1968, she was "bitten by the emergency medicine bug" when she took dinner to her roommate who was doing a shift in the ER.
"I loved that you went from patient to patient and you never knew what was coming in next," Bensen recalls. "I began hanging out in the ER whenever I could because I loved the environment. I'm an adrenaline junkie." As a result, she wanted an internship that was primarily located within the Emergency Department.
Serendipitously, she found herself in the MCP cafeteria one day sitting across the table from Wagner and Ethel Weinberg, MD (HU '61), who was an assistant dean of students. "They asked me what I wanted to do as a resident," she says. "I said that what I wanted to do didn't exist — an emergency medicine residency. Coincidentally, they had been sitting there talking about starting such a program."
Dean Weinberg was very supportive of the idea. She had joined WMC in 1968 to establish the Retraining Program for Women Physicians, for women who had been away from practice. As part of this role, she was also concerned with prevention -— how to help women avoid leaving practice in the first place. "I identified emergency room medicine, with its flexible hours, as an area well suited to women with children," she says.
"With support from the Department of Surgery — and Dave Wagner as the responsible surgeon — we were able to establish an acute care fellowship as part of the retraining program. Getting an internship accredited seemed like a natural next step."
Pam Bensen was recruited to fly to Chicago to testify at the AMA committee that was considering an acute care/emergency medicine residency program. Later, Weinberg also went to Chicago and met with the committee. Eventually, MCP received recognition and approval by the AMA Committee on Medical Education for an acute care internship. It was the only one in the country. Wagner became its program director, and Bensen became its first intern/resident.
THE FIRST INTERNSHIP
The program started with four interns and two full-time faculty members, including Wagner. "In the beginning, the interns were teaching themselves," says Wagner. "I had taught myself," he adds. "We also used faculty from other departments to come in and give lectures, but gradually, as residents finished their emergency medicine residencies, we recruited them to become the faculty."
Bensen remembers, "There was no one in the Emergency Department responsible for me in my first year. There were morning rounds, but most of the time we were on our own. There were no residents above us. None of that was unusual back in 1971.
"The most common question I got was, ‘Bensen, what the hell is an emergency physician?' I answered, ‘You teach me how to take care of your patients between 2 a.m. and 8 a.m. so you can sleep. When you are ready to take care of the patients, they will have had the care you wanted.'
"In the beginning, we did the best with what we had. I felt I got a fantastic education because there is nothing like learning from your mistakes. Plus, back then I was able to follow my patients after they were admitted. I went to the clinic to see the patient when they came back in a week. I was able to think through and analyze what we had done and what could have been done better. That doesn't happen in today's current structure."
The demand for emergency medicine physicians was intense. Hospitals wanted to have emergency-trained physicians running their emergency departments. Among the strongest supporters of emergency medicine residencies were hospital administrators. They wanted individuals who could do the job they wanted done, and this new breed — the emergency physician – was doing the job better than it had been done before.
"At one point, we had 16 to 18 residents per year, plus we started to spin off some subspecialties in emergency medicine such as the toxicology program, which became board recognized," Wagner notes. "Pediatric emergency medicine grew out of activities at MCP, Children's Hospital of Philadelphia and St. Christopher's Hospital for Children, and that has become a subspecialty. We were also developing an Emergency Medicine Services subspecialty, which just recently was formally recognized by the American Board of Medical Specialties."
EVOLUTION AND OFFSPRING
By the late 1970s, emergency medicine residencies were popping up all over the country. (Today there are some 180 programs nationwide.) The American College of Emergency Physicians organized the first Board of Emergency Physicians, on which Wagner served, but the specialty wasn't officially recognized by the American Board of Medical Specialties until 1979. Bensen was the first woman to serve on the board of directors of the American College of Emergency Physicians and, fittingly, served on the committee for graduate education. Also fittingly, MCP published the first emergency medicine textbook.
One of the future emergency physicians who was attracted to MCP's program and, according to Wagner, became key to the specialty was Robert McNamara, MD, who completed his residency in 1985. "He was committed to the idea that you must be certified to be recognized as an emergency physician," explains Wagner. McNamara started the American Academy of Emergency Medicine, which required certification for membership.
Richard Hamilton, MD, HU '87, joined the medical school's Emergency Medicine faculty in 1997 and has led the department since 2006, a period of great growth. His admiration for Wagner knows no bounds. "We owe such a debt of gratitude to Dave Wagner for all his guidance, teaching and example of what an exemplary emergency physician should be," says Hamilton. "Today our department includes emergency medicine specialists and subspecialists in medical toxicology, occupational and environmental medicine, and emergency bedside ultrasound. We also recently appointed Ted Corbin [MD, MCPHU '97] as the department's first vice chair for research."
Emergency medicine continues to grow and change. "We are in an era where baby boomers are retiring every 10 or 15 seconds, creating an older population that will have a need for emergency medicine," says Wagner. "These folks will be living in home care or assisted care or continuing care and will have acute care needs for chronic conditions. With telemedicine, we can do some amazing things at the bedside now in assisted living with a combination of ultrasound and Skyping," he continues. "Someone is always on duty for these calls. That was the genesis of emergency medicine in the beginning and continues to support its growth by managing the patient at the point of the problem rather than transferring them to the emergency department.
"Still," Wagner concludes, "as long as hospitals are part of the health care system, the emergency department will be the hub."