Editing Emergency medicine (section)

== Training ==
There are a variety of international models for emergency medicine training. There are two different models among those with well-developed training programs: a "specialist" model or "a multidisciplinary model". Additionally, in some countries, the emergency medicine specialist rides in the ambulance. For example, in France and Germany, the physician, often an anesthesiologist, rides in the ambulance and provides stabilising care at the scene. The patient is directed to the appropriate hospital department, so emergency care is much more multidisciplinary than the Anglo-American model.

In countries such as the US, the United Kingdom, Canada and Australia, ambulances crewed by [[paramedics]] and [[emergency medical technicians]] respond to out-of-hospital emergencies and transport patients to emergency departments, meaning there is more dependence on these healthcare providers and there is more dependence on paramedics and EMTs for on-scene care. Emergency physicians are therefore more "specialists" since all patients are taken to the emergency department. Most developing countries follow the Anglo-American model: the gold standard is three or four-year independent residency training programs in emergency medicine. Some countries develop training programs based on a primary care foundation with additional emergency medicine training. In developing countries, there is an awareness that Western models may not be applicable and may not be the best use of limited health care resources. For example, specialty training and pre-hospital care in developed countries are too expensive and impractical for use in many developing countries with limited health care resources. [[International emergency medicine]] provides a critical global perspective and hope for improvement in these areas.

A brief review of some of these programs follows:

=== Argentina ===
In Argentina, the SAE (Sociedad Argentina de Emergencias) is the leading organisation of emergency medicine. There are many residency programs. Also, it is possible to reach the certification with a two-year postgraduate university course after a few years of ED background.

===Australia and New Zealand===
The specialist medical college responsible for emergency medicine in Australia and New Zealand is the [[Australasian College for Emergency Medicine]] (ACEM).<ref>{{cite web|title=Health Insurance Regulations 1975 (Cth) Schedule 4|url=http://www.austlii.edu.au/au/legis/cth/consol_reg/hir1975273/sch4.html|access-date=3 November 2013|archive-url=https://web.archive.org/web/20131104170040/http://www.austlii.edu.au/au/legis/cth/consol_reg/hir1975273/sch4.html|archive-date=4 November 2013|url-status=dead}}</ref> The training program is nominally seven years in duration, after which the trainee is awarded a Fellowship of ACEM, conditional upon passing all necessary assessments.<ref>{{cite web|title=HB03 Elements of Training|url=http://acem.org.au/media/publications/HB03_v03_Elements_of_Training__Jan-13_.pdf|publisher=Australasian College for Emergency Medicine|access-date=3 November 2013|archive-url=https://web.archive.org/web/20131106090110/http://acem.org.au/media/publications/HB03_v03_Elements_of_Training__Jan-13_.pdf|archive-date=6 November 2013|url-status=dead}}</ref>

Dual fellowship programs also exist for paediatric medicine (in conjunction with the [[Royal Australasian College of Physicians]]) and intensive care medicine (in conjunction with the [[College of Intensive Care Medicine]]). These programs nominally add one or more years to the ACEM training program.<ref>{{cite web|title=HB10 Joint Training Programs|url=http://acem.org.au/media/member_docs/HB10_v03_Joint_Training_Programs__Sept-13_.pdf|publisher=Australasian College of Emergency Medicine|access-date=3 November 2013|archive-url=https://web.archive.org/web/20131106090103/http://acem.org.au/media/member_docs/HB10_v03_Joint_Training_Programs__Sept-13_.pdf|archive-date=6 November 2013|url-status=dead}}</ref>

For medical doctors not (and not wishing to be) specialists in emergency medicine but have a significant interest or workload in emergency departments, the ACEM provides non-specialist certificates and diplomas.<ref>{{cite web|title=EM Certificate and Diploma |url=http://www.acem.org.au/infocentre.aspx?docId=1251 |publisher=Australasian College of Emergency Medicine |url-status=dead |archive-url=https://web.archive.org/web/20131112033631/http://www.acem.org.au/infocentre.aspx?docId=1251 |archive-date=12 November 2013}}</ref>

The Australian College of Rural and Remote Medicine (ACRRM) is the responsible body for the training and upholding of standards for practice and provision of rural and remote medical care.<ref>{{cite web|title=Australian College of Rural and Remote Medicine Homepage |url=https://www.acrrm.org.au/home |publisher=Australian College of Rural and Remote Medicine}}</ref> Prospective rural generalists undertaking this four-year fellowship program have an opportunity to complete Advanced Specialised Training (AST) in emergency medicine.<ref>{{cite web |title=Advanced Specialised Training |url=https://www.acrrm.org.au/home |publisher=Australian College of Rural and Remote Medicine |url-status=dead |archive-url=https://web.archive.org/web/20230127040902/https://www.acrrm.org.au/home |archive-date=27 January 2023 |access-date=27 January 2023 }}</ref>

=== Belgium ===
{{unreferenced section|date=March 2023}}
In Belgium there are three recognised ways to practice emergency medicine. Until 2005 there was no accredited emergency medicine program. Emergency medicine was performed by general practitioners (having followed a 240-hour course, Acute Medicine) or by specialists (surgeon, internal medicine, neurologist, anesthesiologist) with or without supra-specialty training in emergency medicine.

Since 2005 residency training exists for acute medicine (3 years) or emergency medicine (6 years). At least 50% of the training is in the emergency department; the other part is a rotation between disciplines like pediatrics, surgery, orthopedic surgery, anesthesiology and critical care medicine.

Alternative an attending physician with one of following specialties (anesthesiology, internal medicine, cardiology, gastro-enterology, pneumology, rheumatology, urology, general surgery, plastic & reconstructive surgery, orthopedic surgery, neurology, neurosurgery, pediatrics) can follow a supra-specialty program of two years to become an emergency medicine specialist.

===Brazil===
In Brazil, the first emergency medicine residency program was created at Hospital Pronto Socorro de Porto Alegre in 1996. In 2002, the emergency medical services were standardized nationally with the creation of SAMU (Serviço de atendimento móvel de urgência), inspired by French EMS, which also provides training to its employees. The nacional emergency medicina association (ABRAMEDE – Associação Brasileira de Medicina de Emergência) was created in 2007. In 2008 the second residency program was started at Messejana Hospital in Fortaleza. Then, in 2015, emergency medicine was formally recognized as a medical specialty by the Brazilian Medical Association. After formal recognition, multiple residency programs were created nationwide (e.g. Universidade Federal de Minas Gerais in 2016 and Universidade de São Paulo in 2017). The residency consists of a three-year program with training in all emergency department specialties (i.e. internal medicine, surgery, pediatrics, orthopedics, OB/GYN), EMS and intensive care.<ref>{{cite web|title=Medicina de Emergência no Brasil|url=https://abramede.com.br/a-medicina-de-emergencia-no-brasil|publisher=Associação Brasileira de Medicina de Emergência – ABRAMEDE|access-date=22 January 2023|archive-date=22 January 2023|archive-url=https://web.archive.org/web/20230122013550/https://abramede.com.br/a-medicina-de-emergencia-no-brasil/|url-status=dead}}</ref>

=== Chile ===
In Chile, emergency medicine begins its journey in Chile with the first specialty program at the beginning of the 1990s, at the University of Chile and the University of Santiago of Chile. Currently, it is a primary specialty legally recognised by the Ministry of Health since 2013. It has multiple training programs for specialists, notably the University of Chile, Pontifical Catholic University of Chile, Clínica Alemana – Universidad del Desarrollo, San Sebastian University – MUE and University of Santiago of Chile (USACH). Currently, and intending to strengthen the specialty at the country level, FOAMed initiatives have emerged (free open access medical education in emergency medicine) and the #ChileEM initiative that brings together the programs of the Universidad San Sebastián / MUE, Universidad Católica de Chile and Universidad de Chile, intend to hold joint clinical meetings between the leading training programs, regularly and open to all the health team working in the field of urgency. The specialists already trained are grouped in the Chilean Society of Emergency Medicine (SOCHIMU).

===Canada===
The two routes to emergency medicine certification can be summarized as follows:

# A five-year residency leads to the designation of FRCP(EM) through the [[Royal College of Physicians and Surgeons of Canada]] (Emergency Medicine Board Certification – emergency medicine consultant).
# A one-year emergency medicine enhanced skills program following a two-year [[family medicine]] residency leading to the designation of CCFP(EM) through the [[College of Family Physicians of Canada]] (Advanced Competency Certification).<ref name=CFPC>{{cite web |url=http://www.cfpc.ca/English/cfpc/education/examinations/emergency%20medicine/default.asp?s=1 |title=Emergency Medicine (EM) |url-status=dead |archive-url=https://web.archive.org/web/20090227222859/http://www.cfpc.ca/English/cfpc/education/examinations/emergency%20medicine/default.asp?s=1 |archive-date=27 February 2009}}</ref> The CFPC also allows those are having worked a minimum of four years at a minimum of 400 hours per year in emergency medicine to challenge the examination of special competence in emergency medicine and thus become specialized.<ref name=CFPC/>

CCFP(EM) emergency physicians outnumber FRCP(EM) physicians by a ratio of about 3 to 1, and they tend to work primarily as clinicians with a minor focus on academic activities such as teaching and research. FRCP(EM) Emergency Medicine Board specialists tend to congregate in academic centres and have more academically oriented careers, which emphasize administration, research, critical care, disaster medicine, and teaching. They also tend to sub-specialize in toxicology, critical care, pediatric emergency medicine, and sports medicine. Furthermore, the FRCP(EM) residency length allows more time for formal training in these areas.

[[Physician assistants]] are currently practising in the field of emergency medicine in Canada.

===China===
{{unreferenced section|date=March 2023}}
The current post-graduate emergency medicine training process is highly complex in China. The first EM post-graduate training took place in 1984 at the Peking Union Medical College Hospital. Because specialty certification in EM has not been established, formal training is not required to practice emergency medicine in China.

About a decade ago, emergency medicine residency training was centralized at the municipal levels, following the Ministry of Public Health guidelines. Residency programs in all hospitals are called residency training bases, which have to be approved by local health governments. These bases are hospital-based, but the residents are selected and managed by the municipal associations of medical education. These associations are also the authoritative body of setting up their residents' training curriculum. All medical school graduates who want to practice medicine have to undergo five years of residency training at designated training bases, the first three years of general rotation followed by two more years of specialty-centred training.

===Germany===
In Germany, emergency medicine is not handled as a specialization (''Facharztrichtung''), but any licensed physician can acquire an additional qualification in emergency medicine through an 80-hour course monitored by the respective ''"Ärztekammer"'' (medical association, responsible for licensing of physicians).<ref>[https://aeksa.de/www/website/PublicNavigation/arzt/fortbildung/kursangebote/notfallmedizin/ "Notfallmedizin, Ärztekammer Sachsen-Anhalt"] {{in lang |de}} Retrieved 18 February 2017.</ref> Service as an emergency physician in an ambulance service is part of the specialization training of [[anaesthesiology]]. Emergency physicians usually work on a volunteering basis and are often anesthesiologists but maybe specialists of any kind. Especially there is a specialization training in pediatric intensive care.<ref>[https://www.klinikum.uni-muenchen.de/Herzchirurgische-Klinik-und-Poliklinik/Kinderkardiologie/en/index.html  "Pädiatrische Intensivmedizin, LMU"] {{Webarchive|url=https://web.archive.org/web/20170818065810/http://www.klinikum.uni-muenchen.de/Herzchirurgische-Klinik-und-Poliklinik/Kinderkardiologie/en/index.html |date=18 August 2017}} {{in lang |de}} Retrieved 20 June 2017.</ref>

===India===
India is an example of how family medicine can be a foundation for emergency medicine training.<ref>{{Cite journal|title = Developing Emerg Med Through Primary Care |last1=Cho |first1=E |last2=Akkapeddi |first2=V |last3=Rajagopalan |first3=A |journal=National Medical Journal of India |volume=18 |issue=3 |pages=154–156}}</ref> Many private hospitals and institutes have been providing emergency medicine training for doctors, nurses and paramedics since 1994, with certification programs varying from six months to three years. However, emergency medicine was only recognized as a separate specialty by the [[Medical Council of India]] in July 2009.

===Malaysia===
There are three universities ([[Universiti Sains Malaysia]], Universiti Kebangsaan Malaysia, and Universiti Malaya) that offer master's degrees in emergency medicine – postgraduate training programs of four years in duration with clinical rotations, examinations and a dissertation. The first cohort of locally trained emergency physicians graduated in 2002.

=== Saudi Arabia ===

In Saudi Arabia, the Certification of Emergency Medicine takes the four-year Saudi Board of Emergency Medicine (SBEM), which the Saudi Council accredits for Health Specialties (SCFHS). It requires passing the two-part exam: first and final part (written and oral) to obtain the SBEM certificate, equivalent to a doctorate.

=== Switzerland ===
{{unreferenced section|date=March 2023}}
Emergency medicine is still not recognised as a fully-fledged specialty in a country that has only recently grasped the importance of having an organised acute medical specialty (during the COVID-19 outbreak). Many attempts to organize the specialty have resulted in a subspecialists training pathway, but to this day, internal medicine, anesthesiology and surgery are still vocally opposed to an emergency medicine specialist title.

===United States===

Most programs are three years in duration, but some programs are four years long. There are several combined residencies offered with other programs, including [[family medicine]], [[internal medicine]] and [[Pediatrics|paediatrics]]. The US is well known for its excellence in emergency medicine residency programs, leading to some controversy about specialty certification.<ref>{{cite journal |doi=10.5847/wjem.j.issn.1920-8642.2012.01.001 |pmid=25215031 |pmc=4129827 |title=Emergency medicine in the United States: A systemic review |journal=World Journal of Emergency Medicine |volume=3 |issue=1 |pages=5–10 |year=2012 |last1=Suter |first1=Robert E}}</ref>

There are three ways to become [[board certification|board-certified]] in emergency medicine:
* The [[American Board of Emergency Medicine]] (ABEM) is for those with either [[Doctor of Medicine]] (MD) or [[Doctor of Osteopathic Medicine]] (DO) degrees. The ABEM is under the authority of the [[American Board of Medical Specialties]].
* The [[American Osteopathic Board of Emergency Medicine]] (AOBEM) certifies only emergency physicians with a DO degree. It is under the authority of the [[American Osteopathic Association Bureau of Osteopathic Specialists]].
*  The [[Board of Certification in Emergency Medicine]] (BCEM) grants board certification in emergency medicine to physicians who have not completed an emergency medicine residency but have completed a residency in other fields (internists, family practitioners, paediatricians, general surgeons, and anesthesiologists). The BCEM is under the authority of the [[American Board of Physician Specialties]].

Several ABMS fellowships are available for emergency medicine graduates, including pre-hospital medicine ([[emergency medical services]]), international medicine, advanced resuscitation, hospice and palliative care, research, undersea and hyperbaric medicine, sports medicine, pain medicine, ultrasound, pediatric emergency medicine, disaster medicine, wilderness medicine, toxicology, and critical care medicine.<ref>{{cite web|title=Subspecialty Certification|url=http://www.abem.org/PUBLIC/portal/alias__Rainbow/lang__en-US/tabID__3335/DesktopDefault.aspx|publisher=ABEM|access-date=29 June 2011|archive-url=https://web.archive.org/web/20110906084307/http://www.abem.org/PUBLIC/portal/alias__Rainbow/lang__en-US/tabID__3335/DesktopDefault.aspx|archive-date=6 September 2011|url-status=dead}}</ref>

In recent years, workforce data has led to a recognition of the need for additional training for primary care physicians who provide emergency care.<ref>{{cite journal |doi=10.1370/afm.1209 |pmid=21060129 |pmc=2975696 |title=Family Physicians in Emergency Medicine: New Opportunities and Critical Challenges |journal=The Annals of Family Medicine |volume=8 |issue=6 |pages=564–5 |year=2010 |last1=Gerard |first1=W. A. |last2=Staffer |first2=A. |last3=Bullock |first3=K. |last4=Pugno |first4=P.}}</ref> It has led to several supplemental training programs in first-hour emergency care and a few fellowships for family physicians in emergency medicine.,<ref>{{cite journal |doi=10.1097/01.EEM.0000361892.01557.a0 |title=CALS Training Provides Solution to Emergency Provider Shortages |journal=Emergency Medicine News |volume=31 |pages=1 |year=2009 |last1=Carter |first1=Darrell |s2cid=76410689|doi-access=free }}</ref> and few fellowships for family physicians in emergency medicine.<ref>{{cite web|title=The Department of Family Medicine Emergency Medicine Fellowship|url=http://gsm.utmck.edu/family_medicine/emergencymedicine/main.cfm|website=University of Tennessee Graduate School of Medicine|access-date=16 November 2016}}</ref>

====Funding for training====

"In 2010, there were 157 allopathic and 37 osteopathic emergency medicine residency programs, which collectively accept about 2,000 new residents each year. Studies have shown that attending emergency physician supervision of residents correlates to higher quality and more cost-effective practice, primarily when an emergency medicine residency exists."<ref>{{cite web|url=http://www.aaem.org/about-aaem/aaem-history|title=American Academy of Emergency Medicine|website=AAEM – American Academy of Emergency Medicine|access-date=15 October 2018|archive-date=20 March 2018|archive-url=https://web.archive.org/web/20180320013013/http://www.aaem.org/about-aaem/aaem-history|url-status=dead}}</ref> Medical education is primarily funded through the Medicare program;<ref>{{cite journal |doi=10.1197/j.aem.2004.04.003 |pmid=15231465 |title=Financing of Emergency Medicine Graduate Medical Education Programs in an Era of Declining Medicare Reimbursement and Support |journal=Academic Emergency Medicine |volume=11 |issue=7 |pages=756–9 |year=2004 |last1=Baumann |first1=Michael R. |last2=Vadeboncoeur |first2=Tyler F. |last3=Schafermeyer |first3=Robert W. |doi-access=free}}</ref> payments are given to hospitals for each resident.<ref>{{cite book |last1=Shi |first1=L |last2=Singh |first2=D |title=Delivering health care in America: A systems approach |edition=6th |location=Burlington, Massachusetts |publisher=Jones & Bartlett Learning |year=2015 |page=131}}</ref> "Fifty-five per cent of ED payments come from Medicare, fifteen per cent from Medicaid, five per cent from private payment and twenty-five per cent from commercially insured patients."<ref>{{cite journal |pmid=17694845 |year=2007 |last1=Hatley |first1=T |title=Management and financing of emergency medical services |journal=North Carolina Medical Journal |volume=68 |issue=4 |pages=259–61 |last2=Patterson |first2=P. D. |doi=10.18043/ncm.68.4.259 |doi-access=free}}</ref> However, choices of physician specialties are not mandated by any agency or program, so even though emergency departments see many Medicare/Medicaid patients and thus receive much funding for training from these programs, there is still concern over a shortage of specialty-trained emergency medicine providers.<ref>{{Cite web|year=2012|title=Recent Studies and Reports on Physician Shortages in the US|url=https://www.aamc.org/download/100598/data/|publisher=Association of American Medical Colleges|access-date=28 November 2016|archive-url=https://web.archive.org/web/20161021204254/https://www.aamc.org/download/100598/data/|archive-date=21 October 2016|url-status=dead}}</ref>

===United Kingdom===
In the United Kingdom, the [[Royal College of Emergency Medicine]] has a role in setting professional standards and assessing trainees. Emergency medical trainees enter specialty training after five or six years of [[Medical school]] followed by two years of [[Foundation Programme|foundation training]]. Specialty training takes six years to complete, and success in the assessments and a set of five examinations results in the award of Fellowship of the Royal College of Emergency Medicine (FRCEM).

Historically, emergency specialists were drawn from anaesthesia, medicine, and surgery. Many established EM consultants were surgically trained; some hold the fellowship of [[Royal College of Surgeons of Edinburgh]] in accident and emergency – FRCSEd (A&E). trainees in emergency medicine may dual accredit in [[intensive care medicine]] or seek sub-specialisation in paediatric emergency medicine.<ref>{{cite web |url=http://www.rcem.ac.uk/CEM/document?ID=5690&subID=49 |title=The College of Emergency Medicine. A trainee's guide to Specialty Training in Emergency Medicine |publisher=[[Royal College of Emergency Medicine]] |date=July 2015 |access-date=8 February 2016 |archive-date=15 February 2016 |archive-url=https://web.archive.org/web/20160215054824/http://www.rcem.ac.uk/CEM/document?ID=5690&subID=49 |url-status=dead}}</ref>

===Turkey===
Emergency medicine residencies last four years in Turkey. These physicians have a two-year obligatory service in Turkey to be qualified to have their diploma. After this period, EM specialists can choose to work in private or governmental emergency departments.

===Pakistan===
The College of Physicians and Surgeons Pakistan accredited the training in emergency medicine in 2010. Emergency medicine training in Pakistan lasts for five years. The initial two years involve trainees being sent to three major areas: medicine and allied, surgery, and allied and critical care. It is divided into six months each, and the rest six months out of the first two years are spent in the emergency department. In the last three years, trainee residents spend most of their time in the emergency room as senior residents. Certificate courses include ACLS, PALS, ATLS, and research and dissertations are required to complete the training successfully. At the end of five years, candidates become eligible to sit for the FCPS part II exam. After fulfilling the requirement, they become fellows of the College of Physicians and Surgeons Pakistan in emergency medicine ([https://www.cpsp.edu.pk/fcps]).

Institutions providing this training include Shifa International Hospitals Islamabad, Aga Khan University Hospital Karachi, POF Hospital Wah, Lady Reading Hospital Peshawar, Indus Hospital Karachi and Jinnah Post Graduate Medical Center Karachi, and Mayo Hospital, Lahore.

===Iran===
The first residency program in Iran started in 2002 at Iran University of Medical Sciences, and there are now three-year standard residency programs running in Tehran, Tabriz, Mashhad, Isfahan, and some other universities. All these programs work under the supervision of the emergency medicine specialty board committee. There are now more than 200 (and increasing) board-certified Emergency Physicians in Iran.