REVIEWResidency training in emergency medicine: the challenges ofthe 21st century
Annette L. Williams, Andra L. Blomkalns and W. Brian Gibler
Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH, USA(Received for publication on January 9, 2004)

Abstract. Emergency Medicine is a relatively young specialty in the United States as well as in otherparts of the world. It was only 36 years ago, in 1968, that the American College of Emergency Physicians was founded. Two years later, the University of Cincinnati in Cincinnati, Ohio, USA launched theﬁrst Emergency Medicine Residency Training Program. Until the inception of this program, stafﬁng of‘‘Emergency Rooms’’ consisted largely of physicians who were not trained in the specialty of Emergency Medicine. Emergency Medicine Residency training programs fulﬁll the need to have Emergency
Medicine trained physicians stafﬁng Emergency Departments. There are three and four year training
formats for Emergency Medicine in the United States. The University of Cincinnati program is a full
four-year program, which teaches residents to master the many diagnostic, procedural, and interpersonal skills required of Emergency Medicine physicians. Diagnostic skills must encompass the pathology affecting all organ systems in all age groups and both sexes. Procedural skills include airway
management, vascular access, cavity access, and wound repair. Interpersonal skills are demanding as
well, requiring leadership/management of the Emergency Department care team, immediate patient
rapport, and dealing with patient/family grief. The Residency Review Committee of the Accreditation
Council for Graduate Medical Education (ACGME) ensures that all programs have a structured curriculum complete with both didactic and bedside teaching, as well as structured methods for evaluationof both residents and faculty. According to manpower studies, a great need still exists for Emergency
Physicians in many United States hospitals, particularly in rural communities. (Keio J Med 53 (4): 203–
209, December 2004)
Key words: emergency medicine, residency, specialty training

Introduction
Emergency Medicine is a challenging and complex
ﬁeld requiring speciﬁc training in many disciplines.
Television programs such as 911, ER, Chicago Hope,and Trauma: Life in the ER glamorize this relatively
new ﬁeld of medicine and have projected an imageof emergency department care throughout the world.
There are approximately 5,000 emergency departmentsin the United States with 25,000 physicians practicing
in these centers. Currently more than 2,700 physicians
are being trained in the 132 Emergency Medicine
Residency Training Programs approved by the Accreditation Council for Graduate Medical Education(ACGME) in the United States. The ACGME is a pri-vate, professional organization responsible for theaccreditation (approval) of nearly 7,800 residency
programs in all specialties. Membership of the ACGME
is composed of members from institutions (hospitals),
representatives of the American Board of Medical
Specialties, health care payors, government representatives and the general public. The ACGME accredits 110
specialty and subspecialty programs for ultimate board
certiﬁcation by the 24 member boards of the American
Board of Medical Specialties. Each year these programs graduate approximately 800 physicians that are
eligible to become certiﬁed as Emergency Medicine
specialists. Emergency Medicine has been and continues to be, one of the most competitive specialties for
medical student applicants. The American College ofPresented at the 1326th Meeting of the Keio Medical Society in Tokyo, September 10, 2003.
Reprint requests to: Dr. W. Brian Gibler, Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin
Way, Cincinnati OH 45267-0769, USA
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Williams AL, et al: Training in emergency medicine – 21st century

Emergency Physicians (ACEP), which began with eightphysicians in 1968, now has nearly 20,000 members.
There are more than 4,000 members of Emergency
Medicine’s academic organization, the Society for Academic Emergency Medicine (SAEM). There are 56
departments of emergency medicine within the nation’s
academic medical centers, in addition to more than 20
divisions and sections. Four established peer-review
journals highlight research in the ﬁeld, among many
textbooks, journals, and other publications which emphasize emergency services.
The History of Emergency Medicine in the
United States
The annual number of emergency department visits
has increased exponentially since the concept of the‘‘Emergency Room’’ originated in the early 1960s, withover 105,000,000 patient visits recorded in 2003.1 Three
major factors conspired during this decade to set thestage for the development of this new specialty. First,
an increasingly mobile population did not remain in one
place long enough to establish physician/patient relationships. In addition, third party payers began assuring
payment for outpatient medical services rendered in a
hospital. Lastly, new experiences in Vietnam with thetreatment of traumatically wounded soldiers demonstrated that lives could be saved if skilled patient care
was delivered early, particularly within the ﬁrst hour
after injury. Patient visits to hospital emergency services increased 367% between 1955 and 1971, morethan any other hospital service. Adequate physician
stafﬁng was necessary to meet the increasing patientnumbers presenting to hospital emergency rooms.1–3
The precipitating events that created the specialtyof Emergency Medicine in the United States actuallybegan in the post-World War II era. Epidemiologic,
healthcare, and economic forces were responsible. The
population of the United States increased with the‘‘baby boom’’ resulting from soldiers returning fromthe war in the late 1940’s and early 1950’s, and urban
sprawl became commonplace around major cities. Primary care physicians found themselves unable to makehouse calls any longer and their busy ofﬁce practices
were often so overburdened that they sent patients
directly to the hospital for care. In addition, federal
and third party insurance companies began supporting
hospital-based services more heavily than those provided in the ofﬁce or at home.3–5 Finally, with medical
advances, people began to think of the concept of specialty certiﬁcation in particular medical ﬁelds as a necessity. The cessation of house calls, increasing numberof indigent patients, the concept of specialty training,
decreased access to primary care, and economic reimbursement for hospital-based services caused patients

to come to hospitals for care in ever-increasing numbers.
The number of patient visits to emergency departments
increased 367% from 1955 to 1971.3
Hospitals were evolving as well. Diagnostic andtherapeutic modalities were becoming increasingly sophisticated. Intensive care units, with constant monitoring by skilled nurses, allowed survival of increasingly sicker patients. Unfortunately, the ‘‘Emergency
Rooms’’ of the time were ill equipped and under-staffedto handle the new demands that were placed on them.
An ‘‘ER’’ was often a single room staffed by one nurse
and an on-call, but off-site, physician. In teaching
hospitals, the unsupervised junior house ofﬁcers andinterns provided emergency care. Faculty supervision
was virtually non-existent. In non-teaching hospitals,
emergency care duty was left to disaffected membersof the medical staff such as new specialists, physiologically impaired physicians, or those unhappy with theirown practice. Often these individuals were newly graduated physicians with little or no experience, or those
who could not ﬁnd work in other areas of the medicalcare system. Hospitals desperately needed to improvemethods for stafﬁng their emergency departments.
In 1961, four physicians in Alexandria, Virginia
left their ofﬁce practices and formed the ﬁrst full-time
physician group dedicated exclusively to providing
medical care in the emergency department. James D.
Mills, Jr., MD conceived of this stafﬁng concept, whichbecame known as the ‘‘Alexandria Plan’’. Shortly
thereafter, two other similar stafﬁng designs were
established by other physicians in Pontiac and Flint,
Michigan. These physicians were devoted to emergency
care and searched for information to help improve theirdiagnostic and management skills. However, there were
no educational programs devoted to emergency care atthat time. The next step was the establishment oforganizations dedicated to meeting the professional
needs of career emergency physicians particularly withregard to education and training.1
On August 16, 1968, eight emergency physicians met
in Lansing, Michigan to discuss forming a society thatwould meet the professional needs of career emergency
physicians. At this meeting, the American College ofEmergency Physicians (ACEP) was founded. Twoyears later, the University of Cincinnati launched theﬁrst Emergency Medicine Residency Training Programin 1970.6 By 1975, there were 23 approved residencies
with 100 residents and two academic Departments ofEmergency Medicine. That year the American Medical
Association’s House of Delegates approved a permanent section of Emergency Medicine and accepted
standards for Emergency Medicine residents. In 1979,
the American Board of Medical Specialties (ABMS)
voted to approve the American Board of Emergency
Medicine (ABEM) as a conjoint modiﬁed board.

Keio J Med 2004; 53 (4): 203–209
Table 1

History of Emergency Medicine in the United States

1968
1969
1970

American College of Emergency Physicians formed
Annals of Emergency Medicine founded
University of Cincinnati Emergency Medicine Residency
Training Program started
University Association for Emergency Medical Services
foundedAmerican Board of Emergency Medicine becomes Conjoint(Probational) Board
43 residency training programs in Emergency Medicine
available
Emergency Medicine becomes a separate Department(with Surgery, Medicine, Pediatrics, etc) of the Universityof Cincinnati College of Medicine
American Board of Emergency Medicine becomes a full,
separate board of the American Board of Medical
Specialties
81 residency training programs in Emergency Medicine
Academic Emergency Medicine journal founded
132 Emergency Medicine training programs available
62 Full Departments of Emergency Medicine in the U.S.
Listing of Emergency Medicine on National Institutes of
Health web site with 10 departments having National
Institutes of Health funding

1979
1980
1984

1989

1990
1993
2003
2004

Emergency Medicine therefore became the 23rd ofﬁcial medical specialty in the United States. Certiﬁcation
examinations followed the next year. In 1982, special
requirements for Emergency Medicine residency training programs were approved by the Accreditation
Council for Graduate Medical Education (ACGME).
In 1989, primary board status was granted by the
ABMS. Four subspecialties have been establishedwithin Emergency Medicine: Medical Toxicology, Pediatric Emergency Medicine, Sports Medicine, andHyperbaric Medicine7 (Table 1).
The Development of Academic Emergency Medicine
in the United States
Early milestones in academic Emergency Medicine
are actually noted in legislative documents, rather than
the scientiﬁc literature. In 1966, the National Academyof Sciences published a report entitled ‘‘Accidental
Death and Disability: The Neglected Disease of Modern Society’’, which led to passage of the Highway
Safety Act. This act required all states to develop
regional emergency medical service systems.4 Then, in
1968, the American Telephone and Telegraph Company enabled telephone companies to offer 911 service.
The Emergency Medical Services Act was passed in1973 and provided funding for comprehensive emergency care systems. In 1985, the National ResearchCouncil published ‘‘Injury in America: A Continuing
Public Health Problem’’.8 This document emphasized
the need for integrated pre-hospital, emergency, andin-hospital trauma care. In 1986, congress passed

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the Consolidated Omnibus Budget Reconciliation Act(COBRA), which contained the Emergency Medical
Treatment and Labor Act (EMTALA). This statuterequired that all patients who present to an emergency
department receive an emergency medical screening
examination as well as stabilization regardless of payor
status. Thus, the emergency department has become
the safety net for the entire population, as it is the single point of universal access to healthcare in the UnitedStates.4
There were initially no educational or academic
training programs in Emergency Medicine. ACEP wasfounded in August of 1968 to initiate the process ofeducation and communication among emergency
physicians, and the ﬁrst Emergency Medicine Residency Training Program was established at the University of Cincinnati in 1970. That same year the University Association for Emergency Medical Services(UAEMS) was formed. In 1974, UAEMS invited
Emergency Medicine residents to participate in their
meetings, laying the foundation for what would become the Emergency Medicine Residents’ Association(EMRA).1
UAEMS and ACEP then jointly tackled the formidable task of developing an Emergency Medicine
certifying board and establishing accredited residency
training programs. These organizations had to deﬁne
the content of this proposed new specialty, establish amodel curriculum for residency programs, develop avoluntary residency accreditation body modeled on theestablished Residency Review Committees, incorporatea certifying board, and develop a specialty examination.
Part of the original strategy to gain formal recognitionof this new specialty was to establish a Section Council
on Emergency Medicine within the American Medical
Association (AMA). Therefore, a coalition of UAEMS,
ACEP, and the Society of Critical Care Medicine
formed a Federation for Emergency and Critical Care
Medicine in 1973. The AMA sponsored a conference
that identiﬁed the parameters of undergraduate, graduate, and continuing education for Emergency Medicine. The formal Section on Emergency Medicine wasultimately approved in 1976.1
Meanwhile, many practicing and academic emergency physicians felt it was time for Emergency
Medicine to become a recognized specialty within theAmerican Board of Medical Specialties (ABMS). The
ABMS develops criteria for a specialty to exist. Essentially, those criteria are the following: 1) content domain that represents a distinct area of medicine, 2)certiﬁcation that is tied to Accreditation Council for
Graduate Medical Education (ACGME) accredited
training, 3) a board that is representative of the specialty, 4) broad professional support for the specialty,
and 5) an appropriate evaluation and testing system.

206

In 1975, ACEP established the Committee on Board
Establishment to set the standards for credentialing
and certiﬁcation in emergency medicine. ABEM wascharged with the tasks of developing the certiﬁcation
examination and planning the logistics of its administration. An application for primary board status wasﬁled on ABEM’s behalf by UAEMS and ACEP and
was initially rejected. Several member boards worked
together, however, to form a conjoint board consisting of 19 directors, with 12 additional members
belonging to ACEP, UAEMS, and the AMA. The 7
remaining positions on the Board would belong to
the American Boards of Family Practice, Internal
Medicine, Obstetrics and Gynecology, Pediatrics, Psychiatry, Neurology, and Surgery. Interestingly, these
7 co-sponsoring boards were independently polled
regarding how many months of the Emergency Medicine curriculum should be devoted to components of
their specially. The cumulative curriculum would haveexceeded 15 years of training in Emergency Medicine.
Clearly, an integrated curriculum was needed. A more
appropriate training period was selected (3 to 4 years),and on September 21, 1979 ABEM was formally recognized as a conjoint, modiﬁed specialty board by the
ABMS. Emergency Medicine became the 23rd academic specialty in the House of Medicine. Over 600
emergency physicians presented for the ﬁrst certiﬁcation examination in February, 1980.
During the 1980s, academic Emergency Medicine
expanded, and the number of residencies increased aswell. UAEMS and the Society for Teachers of Emergency Medicine merged in 1989, bringing research andeducation in Emergency Medicine together under one
name, the Society for Academic Emergency Medicine(SAEM). This organization attracts researchers andacademicians in Emergency Medicine to its Annual
Meeting which focuses on promoting academic Emergency Medicine through education and research. A
new organization of residency program directors wasformed, known as the Council of Emergency Medicine
Residency Directors (CORD). These individuals werededicated to the education and training of Emergency
Medicine residents, EMRA continued to expand as
well, claiming two ACEP Council seats in 1989. In recognition of these advances in academic Emergency
Medicine, the ABMS voted unanimously to approve
ABEM as a full primary board on September 22, 1989,
ten years after its approval as a conjoint board. The
number of academic Departments of Emergency Medicine in United States medical schools more than doubled in the early 1990’s and the Association of Academic Chairs of Emergency Medicine was founded in
1989.
Academic Emergency Medicine continues to thrive,with the combined goals of SAEM and ACEP sum-

Williams AL, et al: Training in emergency medicine – 21st century

marized by ‘‘Research Directions in Emergency Medicine’’, a consensus report that was published in March
1996. This paper was based on a symposium ‘‘The Roleof Emergency Medicine in the Future of American
Medical Care’’. The report recommends the following:1) enhanced support for basic, clinical and health services research 2) promotion of collaborative interdisciplinary research 3) development of new systems to
manage clinical information 4) development of new
methods to assess the outcomes of emergency care and5) securing increased funding for Emergency Medicine
research5 (Table 1).
Curriculum
Emergency Medicine Residency Training Programs
fulﬁll the need to have Emergency Medicine trained
physicians stafﬁng emergency departments. In order tobecome an Emergency Medicine trained specialist, one
undertakes the following course of study:7a) 12 years of primary/secondary schoolb) 4 years of undergraduate (college) educationc) 4 years of medical schoold) And ﬁnally 3 to 4 years of Emergency Medicine
Residency Training.
Guidelines from the Residency Review Committee on
Emergency Medicine
There are three basic formats for Emergency
Medicine training in the United States following medical school: 1) three-year programs, 2) four-year programs that include a general transitional ﬁrst year, and
3) four-year programs with all four years focused on
Emergency Medicine. The Residency Review Committee (RRC) of the Accreditation Council for Graduate
Medical Education (ACGME) ensures that all accredited programs have a structured curriculum completewith both didactic and bedside teaching, as well as
structured methods for evaluation of both residents andfaculty. Residents are deﬁned for the following discussion as emergency physicians in training7 (Table 2).
According to the RRC for Emergency Medicine, theProgram Director and faculty of an Emergency MediTable 2
StatesResidency Training in Emergency Medicine in the United

Formats:
16
16
100

1, 2, 3, 4 year programs
2, 3, 4 programs (3 years after separate 1 year internship)
1, 2, 3 year programs (3 years including the internship year)

Adapted from www.SAEM.org and www.acgme.org

Keio J Med 2004; 53 (4): 203–209

cine Residency Training Program must prepare andcomply with written educational goals. All educational
components of a residency program should be linked tothese program goals. An adequate number of patientsof all ages and both sexes with diverse clinical problems
must be available to provide a patient population sufﬁcient to meet the educational needs of Emergency
Medicine residents and residents who rotate in theemergency department from other services such as
Internal Medicine and Surgery. The primary clinicalsite for an Emergency Medicine Residency Training
Program should have residents rotate for 4 months or
longer and have at least 30,000 emergency department
visits annually. The pediatric experience is deﬁned as
the care of patients less than 18 years of age and should
consist of at least 16% of all resident emergency department encounters, or 4 months of fulltime-equivalentexperience dedicated to the care of infants and children. Although this experience must include the criticalcare of infants and children, at least 50% of the 4months should be in an emergency setting. The numberof critically-ill or critically-injured patients treated by
the residents at the primary clinical site should be signiﬁcant, constituting at least 3% or 1,200 of the emergency department patients per year (whichever isgreater) who are admitted to monitored care settings,
operative care, or the morgue following treatment in
the emergency department. Additional critical care experience is required during off-service rotations, such asmonths spent in the medical and surgical intensive careunits.
All residents within the emergency department must
be under the supervision of Emergency Medicine faculty 24 hours per day, 365 days per year. Sufﬁcient faculty must be present to provide the supervision necessary for the care of each patient. Supervision should becommensurate with the resident’s level of training. The
Program Director must ensure that the degree of professional responsibility accorded to a resident is progressively increased throughout the course of training,
and appropriate for skill and experience level of theindividual resident. There should be opportunities todevelop clinical and administrative judgment in theareas of patient care, teaching, administration, andleadership.
A minimum of 6 residents per year of training isrequired in order to achieve a major impact in theemergency department and a cohesive program. This
number also helps to ensure meaningful attendance at
Emergency Medicine conferences, and to foster a senseof residency program and departmental identity.
At a minimum, residents shall be allowed 1 full day
in 7 days away from the institution and free from any
clinical or academic responsibilities, including planned
educational experiences. While on duty in the emer-

207

gency department, residents may not work longer than
12 continuous scheduled hours. There must be at leastan equivalent period of continuous time off between
scheduled work periods. A resident should not work
more than 60 scheduled hours per week seeing patientsin the emergency department and no more than 72 duty
hours per week. Duty hours comprise all clinical duty
time and conferences, whether spent within or outside
the educational program, including all on-call hours.
The Program Director must provide each resident
physician and member of the faculty, in writing and inadvance of the experience, a comprehensive curriculum
speciﬁc to the educational needs of the Emergency
Medicine resident and designed to accomplish thedeﬁned goals and core competencies of the Emergency
Medicine Residency Training Program. The curriculum
shall include the educational objectives for each rotation or other program assignment, as well as methods of
implementation, evaluation processes, and mechanisms
for feedback.
In terms of educational experiences, the RRC
requires each program to offer its residents an averageof at least 5 hours per week of planned educational
experiences developed by the Emergency Medicine
Residency Training Program. These educational experiences should include presentations based on thedeﬁned curriculum, morbidity and mortality conferences, journal review, administrative seminars, and research methods. The RRC recommends that programs
ensure that residents are relieved of clinical duties toattend these planned educational experiences. The
program should require that each resident participate inat least 70% of the planned Emergency Medicine educational experiences.
At least 50% of the training beyond the ﬁrst year
must take place in the emergency department. Of thetotal educational experience, no less than 50% shouldtake place under the supervision of Emergency Medicine faculty. Such experiences can include Emergency
Medical Services, Toxicology, Pediatric Emergency
Medicine, Sports Medicine, Emergency Medicine Administration, and research in Emergency Medicine(Table 3).
As pre-hospital care is an integral and vital part ofEmergency Medicine, there must be a formal, structured resident experience in this area. This should
include participation in paramedic base station communications, emergency transportation and care in theﬁeld including ground units and if possible air ambulance units, teaching and oversight of pre-hospital
personnel, and disaster planning and drills.
Each resident physician must have sufﬁcient opportunities to perform invasive procedures, monitor
unstable patients, and direct major resuscitations of all
types on all age groups. A major resuscitation is patient

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Williams AL, et al: Training in emergency medicine – 21st century

Table 3 Curriculum for Residents in the University of Cincinnati
Emergency Medicine Residency Training Program

The First Emergency Medicine Residency Training
Program: The University of Cincinnati

Year 1
Orientation
Emergency Medicine – 4 months
Orthopaedics
ENT
Pediatric EM
CCU
MICU
Peds Anesthesia
Year 2
Emergency Medicine – 5 months
Peds ICU
Community ED
TraumaObstetrics
Neurosurgery
Elective
Year 3
Emergency Medicine – 6 months
Plastic Surgery
Community ED
SICUElective – 2 months
Year 4Emergency Medicine – 6 months
Community ED
Elective – 4 months (EMS, Toxicology, Administration, Air
Care, etc)

care for which prolonged physician attention is needed
and interventions such as deﬁbrillation, cardiac pacing,treatment of shock, intravenous use of drugs including
thrombolytics, vasopressors, neuromuscular blocking
agents, or invasive procedures such as cutdowns, central line insertion, tube thoracostomy, or endotracheal
intubation are necessary for stabilization and treatment.
The resident must have the opportunity to make admission recommendations and direct resuscitations.
Emergency Medicine Residency Training Programsmust maintain a record of all major resuscitations andprocedures performed by each resident. Only one resident may be credited with the direction of each resuscitation and the performance of each procedure.
The RRC recommends that the staff as a whole,including residents, must demonstrate broad involvement in scholarly activity. Examples of scholarly activities include participation in journal clubs and research
conferences, or involvement in regional or national
professional and scientiﬁc societies. Ideally this involvement is represented by presentations at the organizations’ meetings and publications in their journals,
experiences in research, or a collective review or casereport. The future of Emergency Medicine rests in thehands of those motivated resident physicians who arewell prepared for roles in academics, research, andadministration.

The Emergency Medicine Residency Training Program at the University of Cincinnati Medical Center isknown internationally for excellence in training resident emergency physicians. This program was the ﬁrst
Emergency Medicine Residency Training Program.
Since its inception in 1970, it has maintained a strong
reputation. The program has over 250 graduates, withgreater than 50% of the graduates ﬁlling academic
positions throughout the United States. Graduates arealso located in other countries such as Iceland andTurkey.
The University of Cincinnati Emergency Department was established as the Emergency Medicine specialty itself was evolving. In the late 1960’s, patients inCincinnati were lobbying for better emergency care,and hospitals were recognizing the need to staff emergency departments to handle this greater inﬂux ofpatients. At the Cincinnati General Hospital and University of Cincinnati College of Medicine, Richard Vilter, MD, Chairman of the Department of Internal
Medicine recruited Herbert Flessa, MD, Internist andOncologist to assume the role of Director of Ambulatory Services, including emergency services. The emergency department of Cincinnati General Hospital atthat time saw over 100,000 patients each year, with careprovided by interns from various departments supervised by senior Surgery and Internal Medicine residents. There was no faculty physician supervision. Dr.
Flessa realized that the care in the emergency roomneeded to be improved and recognized the need for a
speciﬁc training program for physicians practicing
Emergency Medicine. Dr. Flessa collaborated with
Dr. Joe Lindner, MD, Medical Director of the Cincinnati General Hospital and Paul Lewis, MD, a Neurosurgeon, to create an Emergency Medicine Residency
Training Program. On July 1, 1970, Bruce Janiak, MD,
became the ﬁrst Emergency Medicine resident in the
United States. He entered a then two-year program to
study Emergency Medicine at the University of Cincinnati Medical Center. The program was approved by the
AMA as a two-year residency which followed a rotatingﬁrst year of training as an intern. At the completion of
Dr. Janiak’s ﬁrst year, three additional residents wereadded as Emergency Medicine residents, and by 1974
the number accepted per year was six. The program has
expanded to the current number of 12 residency physicians per year. In 1975, Dr. Richard Levy assumed the
directorship of the Emergency Medicine Residency
Training Program and eventually the chairmanship ofthe Department of Emergency Medicine. He served inthis capacity until May, 1995 when he was succeeded by
W. Brian Gibler, MD. During Dr. Levy’s tenure, theKeio J Med 2004; 53 (4): 203–209

residency training program became a four-year program with twenty-four hour emergency department
Attending level physician supervision and teaching,attained full departmental status within the College ofMedicine in 1984, and initiated a research focus for thisnew specialty. The University of Cincinnati Emergency
Medicine Residency Training Program is now a full
four-year program, which teaches residents to masterthe many diagnostic, procedural, and interpersonal
skills required of Emergency Medicine physicians.
Diagnostic skills must encompass the pathology affecting all organ systems in all age groups and both sexes.
Procedural skills such as airway management, vascularaccess, cavity access, and wound repair are perfected.
Interpersonal skills are demanding as well, requiring
leadership and management of the care team, immediate patient rapport, and dealing with patient as well asfamily grief. The University of Cincinnati Emergency
Medicine Resident Training Program employs graded
responsibility for development of these skills. Year 1
emphasizes complex diagnostic skill development, while
Year 2 emphasizes procedural skills and ﬂying on thehelicopter air ambulance. Year 3 focuses on the care of
the critically ill patient. Year 4 emphasizes the resident
in the role of leader, educator, and preceptor. Residents
spend approximately 50% of their time, 24 months, inthe emergency department at the University Hospital,
Children’s Hospital Medical Center, and several community hospitals. Residents spend 5 months in criticalcare units, including the Surgical Intensive Care Unit
(ICU), Medical ICU, Neurosurgical ICU, Pediatric
ICU, and Coronary ICU. Other valuable rotations include months spent rotating on Trauma Surgery, Orthopedic Surgery, Plastic Surgery, Anesthesia, Otolaryngology and Obstetrics. There is also ample elective
time for residents to explore interests that include, but
are not limited to, Toxicology, Hyperbaric Medicine,209

EMS, Air Care (the hospital’s critical care air transport
service) or development of their skills as a researcher or
clinical educator.
Conclusion
Emergency Medicine is a complex ﬁeld requiring
speciﬁc training in many disciplines. Over the last 33
years, training in the ﬁeld of Emergency Medicine has
evolved from a single program at the University ofCincinnati Hospital to 118 programs throughout theUnited States. The breadth and depth of Emergency
Medicine training challenges residents and faculty tostrengthen the ﬁeld through research and innovativeeducational experiences.
References
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2. Haller JS Jr: The beginnings of urban ambulance service in the
United States and England. J Emerg Med 1990; 8: 743–755
3. National Research Council: Accidental Death and Disability: theNeglected Disease of Modern Society, Washington, DC, National
Academy of Sciences, National Research Council, 1966
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and Institute of Medicine, Washington, DC, National Academy
Press, Washington DC, 1985
5. Bowles LT, Sirica CM, eds, The Role of Emergency Medicine in
the Future of American Medical Care, Proceedings of a Conference, New York, Josiah Macy, Jr. Foundation, 1995
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Engl J Med 1996; 334: 642–646
7. Storer DL: In: King AG, ed, History of Medical Specialties inCincinnati, 1997
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Medicine, http://www.acgme.org/downloads/RRC_progReq/
110pr101.pdf