“You are brave!” Starting a life-long career in emergency medicine

Authors: Liam Barrett, Thomas Shanahan  / Editors: Rob Hirst, Govind Oliver / Codes: / Published: 02/10/2020

“You are brave,” is a typical response of family, friends and colleagues, when we say we want to be emergency physicians. This has become pronounced over the last few months, as emergency departments have responded to the COVID-19 pandemic. 

The challenge: “What would make emergency medicine a speciality for life?”

In this year’s national interviews candidates we’re asked, “what would make emergency medicine a speciality for life?” So much has changed since we had to answer this question. 

The COVID-19 pandemic has shone a bright light on the provision of emergency care and highlighted the unique challenges the speciality faces. At the start of the pandemic, emergency departments had to create separate areas to deal with patients presenting with potential COVID-19 symptoms. A few weeks ago, with decreasing attendances for non-COVID-19 related symptoms, emergency physicians had to remind the public to come to hospital if they have chest pain or signs of a stroke. Now with emergency department attendances increasing again they have to be re-designed to ensure social distancing and prevent nosocomial spread of COVID-19. 

The question is, will our emergency departments and roles as emergency physicians ever look the same again? Do we want them to look the same? Before the pandemic, departments were crowded and emergency physicians were struggling day and night to provide the best care they could under enormous pressures. The Royal College of Emergency Medicine (RCEM) President has recently said, “if departments are crowded, we cannot protect patients and staff. Crowding has long been associated with avoidable mortality, and COVID-19 reinforces and multiplies this risk.”¹

How NHS care is delivered has changed substantially for some specialities, with increased utilisation of virtual clinics and telephone consultations. However, in emergency departments, there has been little room to shield the team from the influx of undifferentiated patients coughing, fighting, vomiting, spitting and deteriorating in front of us, often without warning. Emergency physicians are rightly asking whether a new model of care is possible. They are looking at places such as Norway and Denmark and asking should access to emergency care require prior referral from GP or NHS 111? 

It is clear that entering a career in any speciality can be personally and professionally challenging. Emergency medicine has a reputation of being incredibly rewarding and stimulating intellectually, but also having its own unique stresses. 

From our experiences and discussions with colleagues we identified the following factors that make people think twice about emergency medicine as a life-long career: frequency of unsocial hours, lack of flexibility in rotas, crowding reducing opportunities to learn and provide safe care. The cumulative effect is the potential to demotivate trainees and result in burnout.

However, over the last few years RCEM and the Emergency Medicine Trainees Association (EMTA) have recognised these concerns and tried to focus efforts on improving the speciality.² Emergency medicine led the way as a pilot specialty for less than full time (LTFT) working without needing a reason. Departments around the country have introduced annualised hours and self-rostering for trainees and through clinical fellow roles, protected time to pursue other interests, such as research, global health, medical education and prehospital emergency care.  

Optimistic outlook: “We believe there is a lot to be encouraged by”

For us as trainees starting academic training in emergency medicine, we believe there is a lot to be encouraged by. In 2019, there was an increase in the number of applicants for emergency medicine training³ and there were seven universities and associated NHS trusts recruiting for ACF posts in emergency medicine. 

Securing integrated clinical academic training posts counters some of the negatives of current speciality training. In particular over a career it offers a more sustainable rota with protected time for research and career fulfilment through an opportunity to try and answer urgent research questions that could improve emergency care. It also comes with opportunities for a change of pace and working with different colleagues. Could this be the norm for all trainees? Should training programmes be learning from clinical fellow posts and giving protected time for higher specialist trainees to pursue other interests and skills development? This might be a way to maintain enthusiasm in the specialty over the long term. 

There is currently an open themed call from the National Institute for Health Research (NIHR) for research into emergencies; in addition emergency medicine was selected as an NIHR incubator, which is national display of support for clinical academics in emergency medicine. This impressive combination offers the opportunity to reverse a worrying trend in a decline in emergency medicine publications in the UK over the last five years.⁴ 

It is an exciting time for trainees with many schemes set up to facilitate academic careers such as RCEM research grants and young investigator of the year award. In addition, trainee research has grown significantly with the establishment of the Trainee Emergency Research Network (TERN). TERN has successfully engaged emergency medicine staff in potentially practice changing research across the UK. 

As we get ready to embark on a career in academic emergency medicine we think more control over our careers, in terms of rotas and professional development, including structured research training through NIHR and working collaboratively in research networks, such as TERN will be key to ensuring a life-long career in academic emergency medicine is possible. 

So are we brave enough? We will certainly find out!

Biographies

• Dr Liam Barrett started his ACF in emergency medicine in August 2020 and is based in Cambridge.
• Dr Thomas Shanahan started his ACF in emergency medicine in August 2020 and is based in Manchester. 

References