General overview – Emergency medicine
|Description of specialty||Emergency medicine is a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of episodic undifferentiated physical and behavioural disorders; it further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development.14|
|Number||There are just under 1000 emergency medicine specialists licensed to practise in Australia.15|
|Gender mix||25% female, 75% male.|
General overview – Intensive care medicine
|Description of specialty||Intensive care medicine concerns the provision of the continuous and closely monitored healthcare that is provided to critically ill patients. Sub-specialties include: Toxicology, Disaster Medicine, Hyperbaric Medicine, Ultrasound, Paediatrics, Retrieval Medicine, and International relief/disaster.|
|Number||There are 429 intensive care medicine specialists.|
|Gender mix||25% female, 75% male.|
Emergency and intensive care medicine specialists and eHealth
Examples of relevant eHealth applicationsSome example uses of eHealth that emergency and intensive care medicine specialists currently and could possibly benefit from include:
- Unlike some other specialities, there is heavy use of decision-support tools in Emergency and ICU medicine, due to the sheer range of acute conditions encountered in this type of practice
- Support for a shared EHR is likely to be very high in this group due to the nature of their work
- ePrescribing programs and clinical algorithms are frequently used
- There are some applications for telehealth that can reduce the potential for unnecessary transfer to hospital.
Current eHealth ‘position’The biggest issue for this specialist group is the past medical history and some kind of reliable shared record, which documents medications, allergies, and diagnostic tests, as most sick patients presenting to hospitals have a minimum of information with them and cannot give a reliable history. If the hospital has no accessible record then the doctors have nothing to go on, this is when errors are made and tests get duplicated, which occurs far too often. Lack of connectivity and hospital inconsistency in their level of sophistication in record-keeping – some are electronic, some are paper, with many stages in between – is a very big problem in this area.
Emergency medicine specialists are generally very technologically competent in their personal use of IT; however this does not always translate into professional competence to use eHealth tools. This is due to a lack of undergraduate training in IT, and they are time poor in the workplace once they graduate. Although they work set shifts, once they are at work they are very busy and often do not have time to sit down – any new system must have a user interface that is extremely simple and quick to use.
The Australian College of Emergency Medicine (ACEM) is using eLearning to address some of the gaps with eHealth readiness for trainees and fellows. Most of this activity has been funded through a variety of government grants. The elearning options are seen to be important for rural trainees due to the perception that city doctors do better in their exams as a result of better supervision. An e-portfolio is being introduced for trainees to encourage reflective learning and a proactive approach to quality and dealing with errors. Fellows are also offered training in this area.
Some hospitals are using telehealth technologies, mainly in rural areas to limit unnecessary admissions of more remote patients. These can be as simple as photos sent online, or Skype, depending on the hospital and the enthusiasm of individual specialists.
The ACEM also provides very specific visual resources online for international medical graduates seeking specialist recognition as many of these are working in rural hospitals. These are provided in a way that enables them to improve their skills in a ‘no-risk no-fail’ environment. This is also a government-funded program.
Intensive care medicine fellows are very technologically savvy and are pushing the College of Intensive Care Medicine (CICM) towards greater engagement with online tools and eHealth. The College has a Facebook page and social networking approaches to educational activities such as online chats on a particular topic. iPhone apps are also used very widely for educational and work processes. The CICM is looking to provide more education and other facilities like forms and exams online to meet demand from trainees. Digital images are currently used in the exams as this is how hospital residents are now trained to view them. They are soon to start a digital journal library as they no longer have access to the one at the ANZCA.
There are two major issues facing ICU specialists that eHealth can address:
Provision of assistance to rural and regional Australia in terms of advice, trainee supervision and retrievals. Many smaller hospitals have the ability to ventilate patients but the doctor present is either an international medical graduate or an anaesthetist who is not a fellow of the college due to workforce shortages in the regions. The international medical graduates are mostly from India – there are some very good hospitals in India providing ICU training, however language can be a major barrier. Skype is used a lot when communicating with rural hospitals to provide support, however the College has needed to set minimum standards for how such a consultation should occur to avoid errors. A high quality medical record providing timely access to relevant information is very important in these circumstances. Queensland Health has been the leader when it comes to addressing some of the issues faced by rural hospital practitioners.
Communication is a key skill, particularly when talking to families about end-of-life decisions. Both colleges provide training in this area. Good access to medical records across hospitals is critical to record advance directives and decisions about resuscitation that may have been made. Skype can also be used in this scenario. Providing education online is important in this area too.
Unfortunately there is enormous variation in the hospital system in terms of what IT facilities are available, ranging from completely paperless facilities, to those with nothing, with ICU specialists needing to bring in their own equipment from home.
Key insights from eHealth readiness survey
- Emergency medicine practitioners are above-average eHealth users and are especially likely to use computers to view pathology results (92 percent) and view diagnostic imaging results (91 percent). Their hospital-based location often provides them with easy access to both of these time-saving applications
- Emergency medicine practitioners are much more likely to use telehealth (18% currently use, versus 9% of all medical specialists). Of those interested in telehealth, the most appealing uses include training (74 percent of those who definitely or probably will use telehealth within the next three years) and consultations with practitioners (67 percent)
- A sizable number of emergency medicine practitioners are already using computers to order tests (41 percent for pathology tests and 36 percent for diagnostic imaging) and interest is strong among those who don’t yet have this capability (55 percent would like to order pathology tests online and 58 percent would like to order diagnostic imaging)
- Similarly, interest in computerised decision support is high (79 percent are interested in interactive decision support for prescriptions and 70 percent are interested in interactive decision support for ordering diagnostic tests). Because emergency medicine practitioners are exposed to a wide variety of cases and conditions, they are often more likely to find interactive decision support applications relevant and helpful. This is especially true among younger practitioners and trainees
- Although just 26 percent currently share health records electronically with other practitioners, 72 percent would be interested in doing so in the future
- Of all specialists, emergency medicine practitioners are the most interested in accessing shared patient health summaries (84 percent strongly agree versus 51 percent of all specialists). Access to basic health information is especially critical in this specialty because patients are not always able to communicate the information themselves, and GPs can be very difficult to reach during non-business hours
- Emergency medicine practitioners are also especially likely to agree that they are expected to use computers in their specialty (81 percent strongly agree) and that most practitioners in their network use computers (79 percent strongly agree)
- Similar to the diagnosticians, emergency medicine practitioners are very technologically savvy. Of all specialists, they are the most interested in maintaining up-to-date computer systems (55 percent strongly agree that this is important to them), and 43 percent strongly agree that they like to be early adopters of new computer systems
- Emergency medicine practitioners perceive many benefits from eHealth, especially in improving the quality and provision of care. The leading benefits include:
- Improved collaboration (60 percent strongly agree)
- Improved continuity of care (56 percent strongly agree)
- Increased patient safety (46 percent strongly agree)
- The leading barrier for emergency medicine practitioners is external connectivity (40 percent strongly agree), which prevents them from accessing and sharing information electronically outside of their immediate hospital environments. Internal connectivity is also a strong barrier (37 percent strongly agree), as is the concern about malfunctions or downtime (38 percent strongly agree). Access to IT support is also more of a barrier for emergency medicine practitioners as compared with other specialties (28 percent strongly agree versus 17 percent for medical specialists in general)
- As compared with other medical specialists, emergency medicine practitioners are somewhat more likely to be influenced by professional bodies (27 percent strongly agree) and other practitioners in their network (20 percent strongly agree). These specialists tend to work closely with other practitioners on a regular basis due to their hospital environments, which helps explain the relevance of peers in influencing their decisions.
Characteristics and practice attributes
General workforce trendsThere is a workforce shortage of fully qualified emergency medicine specialists due to increasing demand, although this is predominantly in rural and regional Australia. International medical graduates who do not speak English as a first language often fill these posts. Most are from India, Pakistan or South East Asia, working under Area of Need provisions. At one stage it was thought that there could possibly be an oversupply of intensive care medicine specialists, however this has not proven to be the case. The College of Intensive Care Medicine (CICM) theorises that this is related to the increasing complexity of cases being undertaken in private hospitals and the need for high dependency services in the private sector as a consequence.
A high-level practice profile of survey respondents suggests:
- Most specialists in the emergency and ICU category work in one hospital, occasionally two or more if they choose a part-time private appointment for some shifts per week
- As these are both specialties where the training and the majority of the work occurs in the public sector, this is where most of these practitioners are located. The introduction of private sector emergency departments and high dependency units has been relatively recent, and it is only in a select few private hospitals that very sick and complex patients are seen in these settings.
Education, registration and accreditationThe Australasian College of Emergency Medicine (ACEM) is the organisation responsible for training emergency medicine specialists and maintaining standards in Australia.
The ACEM is relatively new, with emergency medicine being formally recognised as a speciality in Australia in 1993.
The Australasian College of Emergency Medicine
34 Jeffcott Street, West Melbourne VIC 3003
T: +61 3 9320 0444
F: +61 3 9320 0400
The Australasian College of Intensive Care Medicine (CICM) is the organisation responsible for training intensive care medicine specialists and maintaining standards in Australia.
The CICM was established in 2008 and formally took over the responsibility for training and certification of intensive care specialists from ANZCA. ICM specialists trained prior to 2008 have a joint fellowship either through ANZCA or RACP.
College of Intensive Care Medicine of Australia and New Zealand
Suite 101, 168 Greville Street, Prahan VIC 3181
T: +61 3 9514 2888
F: +61 3 9533 2657
Training in emergency medicine generally commences in the third postgraduate year, and occurs in a college-accredited emergency department. A fellowship examination must be successfully completed. By way of summary:
- Dual training programs for combined fellowships in ICU or paediatrics are available, and have minimised the amount of required time and number of exams
- The training requirements of the College of Intensive Care Medicine training program in General Intensive Care includes 12 months General Hospital Experience post graduation plus 36 months of basic training and 36 months of advanced training.
- A six year training program comprising three years of basic training and three years of advanced training, which must include:
- Thirty six months of intensive care training. Twelve months may be undertaken in Basic Training in units approved for training. Twenty four months of core intensive care training must be undertaken in Advanced Training in an intensive care unit approved for core training. One core year of intensive care training must be continuous
- The second core year of intensive care training may be spent discontinuously in two periods of six months each. At least 12 months must be undertaken in a unit or units accredited as C24, and only one rotation to a unit classified as C6 is permitted without prior approval of the Censor. In-Training Assessments for this period of training are required. At least six months of intensive care training must be undertaken as a Senior Registrar. A maximum of 24 months of intensive care training, whether basic or core, can be completed in the same unit.16
Sources of financial reimbursement/role in the healthcare ecosystemMost emergency medicine fellows and trainees are employed in the public sector as this is where the accredited training positions are – only six private hospitals around Australia have EDs accredited for training purposes, compared with 130 in the public sector. These are for the most part salaried employees. There is however considerable growth in the provision of private emergency department services, for which fee-for-service is charged and rebates are available from the private health funds or Medicare.
ICU Medicine specialists work as salaried employees in public hospitals, and now increasingly in high-dependency units in the private hospital sector.