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The History of Emergency Medicine

Each year the ACOEP receives requests from people investigating a career in emergency medicine. In the early 1990's we began gathering information to provide to those seeking information and have dredged up information from sources that have ranged from interviews to online searches. Recently, we found a very comprehensive look at emergency medicine called, Anyone, Anything, Anytime, A History of Emergency Medicine by Brian J. Zink, M.D., a synopsis of what we found in this book and by searching the website this is found below.

Part 1 - The Beginnings of a Specialty

Medical care became a specialty unto itself during the 1800's. Medical Schools were few and most practitioners of the medical arts were trained by physicians who either attended the few medical schools on a preceptor basis or worked for a person considered a 'healer' by society. During this century medical schools of varying quality began to educate and produce medical doctors who completed medical school and went from classroom to practice without the requirement of internship or residency training. This system produced medical doctors who were generalists and could diagnose basic illnesses, deliver babies and do surgery. These General Practitioners (GPs) worked from their offices and provided "emergency care" to patients in the form of house calls. These physicians were considered valuable assets to any community and worked 24 / 7 providing to the needs of their patients. By the early 1900s, change began to invade the world of medicine.

In 1910 the Flexner Report brought changes to the medical profession promoting standardized basic medical education and developing a link between the medical school and hospital. The Report standardized medicine by requiring that practitioners graduate from an accredited school of medicine and promoted at least a one-year training requirement, called an internship. The Report, called for by the medical community and changes in the science of medicine, was further strengthened by the government when a one year internship was required by the Surgeon General for anyone wishing to practice medicine in the Army during World War I and was endorsed by the medical community for anyone wishing to be a GP in the 1920's. At the same time, medical specialties like Surgery, Ophthalmology, Otolaryngology and Internal Medicine began to solidify as specialties requiring advanced training, beyond the internship, to practice in these areas and become a "specialist" in these fields.

With the growth of these medical specialties, a link was forged between specialty physicians and hospitals to provide, not only education, but patient care. As the physician began to establish these links with hospitals and began certification processes to verify training and abilities, they began forming offices outside of their private residences and in areas surrounding hospitals where they were provided practice privileges. General practice was viewed by many a rudimentary education in medicine and was often used as the pre-requisite for training in specialty medicine. However, because GPs were the largest group of physicians in America, most emergency care was still conducted by the GP at patients' homes. The number of house calls dropped significantly after WWI and didn't disappear until the 1960's or later in more rural areas, when more general practitioners were given staff privileges at hospitals.

During the late 1920's through 1955 more specialty practices were established and patients began to seek out specialists for medical care. Prior to this time, over 75% of medical practitioners classified themselves as GPs, after 1955 this decreased to 50% and by the middle of the 1960's only 31% classified themselves as GPs.1

Medical specialists were again given a boost when physicians were classified in the military by their specialty training during World War II and Korea, when it was driven home that the Veterans Administration ranked specialists higher in military rank than general practitioners, spurring thousands of veterans and GPs to seek specialty training after the war.

Part 2 - Early Emergency Care

With the growth of the specialist and the development of a strong hospital system, emergency care evolved. Prior to this time, office visits and house calls were the primary method for delivering medical care to the public. However, as we moved from World War II, medicine was also breaking ground. Science was changing the face of life for the world, and medical treatment was not immune to change. Physicians used battlefield techniques learned in the previous world war and enhanced by new antibacterial treatments to treat more patients successfully and to transport to field hospitals and MASH units.

Likewise, as these physicians returned from the War and moved into hospitals they brought this experience back to the practices from whence they came. Additionally, with the shift in medical care from generalist to specialists physicians found that they could treat more patients utilizing new medical devices and treatments if they shifted their medical practices from private offices to hospital networks. This move was reinforced by the government with the passage of the Hill-Burton Act of 19462 which promoted national healthcare and the establishment of more hospitals, especially in rural and under-served areas of the county. However, after much dispute this initiative provided over 10 billion dollars of support in the development of hospital networks over the next 20 years.

As hospitals progressed in their medical care, emergency rooms were established to receive patients for admission to their hospitals. However, due to the decline in physicians, through attrition in the number of general practitioners entering practice and a huge number of physicians retiring, medical care in these new ERs was subjugated to medical students and residents. Some ERs were run under the supervision of RNs who triaged patients for care by calling physicians to ask if they could come to the emergency room to treat specific patients or symptoms. Other ERs were staffed by foreign physicians or other physicians who were uncredentialed or unqualified to treat patients due to their own incompetence, criminal records, or addictions.

Emergency care of patients was first described in the late 1940's medical text by British author C. Allan Birch who focused on medical as opposed to surgical emergencies, and then expanded upon by later texts on medical emergencies published in the 1950's and 1960's. The first comprehensive text on emergency medicine was written in 1954 by Thomas Flint, Jr., M.D. and called, Emergency Treatment and Management  and dealt with an alphabetical listing of conditions only.