The developing challenge of clinical longevity

Abstract

Twenty-five years on from the first fellowship examination of the College, it is timely to reflect on the issue of clinical longevity. The pressures of the emergency medicine workplace are relatively unique among the medical specialties, and might require unique solutions if emergency physicians are to continue clinical practice in the latter stages of their careers.

June 1986. Twenty-five years ago. Fourteen keen young (and not so young) doctors approach the first fellowship examination, a daunting 3 day process, in a new specialty. The Australasian College for Emergency Medicine, a product of the bold vision of a group of ‘casualty directors’, had been formed 3 years earlier, and had its first Primary examination 2 years before. These 14 doctors, of various backgrounds and experience, some already employed as consultants in EDs in Australia, were taking a punt. And a serious punt at that. Rather than choosing an established specialty, with some certainty about their career paths and prospects, these 14 candidates were putting their faith in the wisdom and enthusiasm of their elders, aiming for as yet untested career paths as a new breed of acute medicine clinicians.

I recall my friend Ron Hirsch, then Director of the ED at Royal Perth Hospital, Perth, Western Australia, Australia, asking me whether I thought it was possible to spend a whole career in this difficult environment. How would one still maintain the enthusiasm and energy to work in this enormously pressured workplace at the age of say 60? It was a really good question, and one that is now particularly worth asking. As the seven surviving (of eight) graduates of that first fellowship examination approach that age, with barely a few clinical hours in EDs between them, it is worth reflecting on the possibilities for career progression in this specialty. Those eight graduates have mostly had varied and significant careers, both within and without emergency medicine, including appointments to university chairs, senior positions within national and international emergency medicine organizations, chairing the Committee of Presidents of the Medical Colleges and more recently, Chief Medical Officer of Australia. Largely, their career paths have taken them away from clinical emergency medicine. Unlike many other medical specialists, like cardiologists or orthopaedic surgeons or dermatologists who might be somewhere at the peak of their clinical practice approaching 60 years of age, emergency physicians might find they need other strings to their bow to allow them to practise in ways and environments that are more conducive to professional longevity.

We have seen an explosion of emergency medicine subspecialties and special interests in Australasia in recent years. Toxicology, hyperbaric medicine, ultrasound, research, education, international aid, wilderness medicine and others, and overlapping practice with intensive care, paediatrics and medical administration, among others. Many young fellows are developing highly valued expertise in these areas, running poisons centres, directing research at tertiary hospitals, overseeing undergraduate and postgraduate curricula and teaching, leading university departments, coordinating overseas relief operations, running hyperbaric units, spending whole clinical shifts performing ED ultrasound, serving as director of medical services at major teaching hospitals, and practising in paediatric EDs or intensive care units. The specialty really has arrived.

Did the founding parents of the specialty ever envisage this? Or were they more like Thomas J Watson, head of IBM, to whom the following famous prediction is credited: ‘I think there is a world market for maybe five computers’? It is hard to imagine they could have foreseen that there would be over 1400 fellows in Australasia 25 years after that first Fellowship examination. Certainly, as one of the candidates, I could not have predicted how important the specialty was to become in the health system. I recall sitting next to Tom Hamilton, then President of the College, on the flight home to Perth after the exam, not knowing what to call myself when introduced to a specialist colleague. I ended up saying I was an emergency physician when asked what I did, but his quizzical look indicated his surprise that such a specialist existed. And of course, it was not until specialty recognition by the National Specialist Qualifications Advisory Committee some 7 years later that we really were recognized in Australia, and 2 years later in New Zealand.

Specialty recognition, and the various other forms of recognition that emergency medicine has achieved over the 25 years, is one thing. But professional longevity is another. We have grown up in what has naturally been seen as a young specialty, and as a career for young practitioners, because that is the age profile of an establishing specialty. That has had some consequences both clinically and medico-politically. The College Council and other committees have for example always been populated by fellows rather younger than those in similar positions in other colleges. And sometimes our policy and decision-making as a college has reflected this eagerness and enthusiasm for change, with occasional collateral damage.

But the issue we need to come to terms with as a specialty is the coming ‘baby boomer’ phenomenon, as we see a large number of fellows reach an age where they might struggle with the pressures of the work environment in emergency medicine, including shift work and unsociable hours, but more particularly the enormous demands created by time-critical management of multiple simultaneous patients punctuated by frequent and continual interruptions. Further, a considerable proportion of clinical time might now be spent juggling patients and flow in a never-ending and disheartening effort to compensate for chronically over-occupied hospitals with poor bed management practices. In general, these are not issues that many other medical specialists face. Sitting in a quiet carpeted consulting room, seeing a patient at a time, generally with a strict code of no interruption, or operating in a controlled theatre environment, with only one task to complete, are practice modes that sit relatively comfortably with advancing age. Being interrupted at 23.30 hours on a Friday night in the middle of a time-critical resuscitation to intubate a just-arrived unknown patient in extremis, while negotiating in the background with a hospital administrator to go on ambulance bypass, is not.

One solution appears to have been devised by the first eight fellows by examination: get another string to your bow that will allow at least some alternative practice away from these pressures. But should we be advocating career diversion for these highly trained and experienced clinicians at what would be a peak period of clinical expertise for most other specialists? Should we not be considering some other solutions? Perhaps being a consultant in emergency medicine should be more than just a name, but a practice description, and ED consultants should really be paid to consult. That is, senior consultants might have relatively little direct clinical load, but provide senior, experienced input at point of first referral from departmental colleagues, either junior consultants or registrars in training. Perhaps there are other models of practice that need to be explored to help retain the expertise and experience of these extremely valuable emergency physicians in clinical emergency medicine. Perhaps we should be exploring alternative ways of rostering the workforce to reduce the burden of out-of-hours work for more senior consultants.

It would be a great shame if the implication in Ron Hirsch's question 25 years ago, that we are going to have to find something else to do in the latter part of our careers, became the normal career trajectory for Australasian emergency physicians. It is our patients and the health-care system that would suffer if they were to miss out on the accumulated expertise of this group of experienced and capable clinicians.

Competing interests

GAJ is the Emeritus Editor of EMA.