The future of emergency medicine in Australasia

Emergency medicine is sick. Right now, across Australia and Aotearoa New Zealand, EDs are overflowing with patients. Some have received all the care they need from ED staff, but are waiting to see busy inpatient specialists. Others are waiting for beds on wards that are already beyond capacity. Some tried to see their general practitioner when they became unwell a week ago, but there were no available appointments, and their condition worsened, necessitating an ED visit. Many have been assessed by the triage nurse as needing assessment within 30 minutes, but because of overcrowding, they will wait several hours; some will deteriorate before they see a doctor; occasionally, they will die waiting. Increasing numbers of the people waiting in the ED did not decide for themselves to come here: they are residents in understaffed aged care facilities with no after-hours medical care, and have been sent by ambulance after a fall or change in condition. They will spend 12 hours under fluorescent lights being needled by nurses, poked by physicians, missing medications and foregoing food, only to be sent home after a normal CT scan. As the cycle continues, pressure and temperature keep rising in the ED.

ED doctors want to serve their communities, but many are struggling in these unsustainable conditions.¹ They were trained to assess, treat, and disposition undifferentiated patients, resuscitating those who require it. Increasingly, they spend their time scanning a screen of unseen patients for risk of deterioration, debating a difficult disposition with a subspecialist over the phone, and attending to the complex needs of boarding inpatients. Overcrowding forces them to focus on optimising flow through an overwhelmed department, rather than walking with individual patients through their ED journey. It also eats into non-clinical time, at the expense of maintaining their skills as a critical care practitioner. Trainees are thinking about how things will look in 10 years; some are wondering if this is really what they want to do.

Overcrowding is a syndrome. ACEM has worked hard to diagnose the causes,^{2, 3} but because these almost all originate outside of ED, they are difficult for ACEM and emergency physicians to address directly, requiring action from governments and other parts of the health system. In 2023, the Emergency Medicine – Building our Future Summit⁴ saw the coming together of College leaders, fellows and trainees, to discuss a way forward. Changing demographics and the expanding demands placed on us by overcrowding were highlighted. In response to this thin-spreading of our scope, and commensurate with trends elsewhere in medicine, the role of subspecialisation was discussed. In this issue, Metcalfe provides a timely review of the state of emergency medicine subspecialties and special interest pathways.⁵ Protected opportunities to develop clinical and non-clinical interests and master special skills would help us to build sustainable, rewarding careers, despite the pressure on EDs. Overall, although, it seems that emergency physicians remain committed to the core purpose of acute generalism.⁶

Just as doctors learn from clinical experience, it is natural to ask whether emergency medicine in Australasia can learn from the afflictions of emergency medicine elsewhere in the world. The UK's National Health Service (NHS), a beacon of public healthcare since its founding in 1948, has many parallels with the public health system in Australia and particularly New Zealand. Pressure has been mounting on the NHS for several decades and was acutely exacerbated by the COVID-19 pandemic, the effects of which are still being felt. In this issue, Shanahan⁷ draws on his recent experience in UK EDs to offer a prognosis for emergency medicine in Australasia, should things continue on their current trajectory. He recommends NHS-proven treatments for overcrowding that address underlying causes, differentiating these from superficial salves that offer, at best, only a transient appearance of improvement. His warnings are particularly pertinent in light of recent political pressure to water down standards and normalise ED overcrowding in both Australia and New Zealand.

Our two FACEM authors are optimistic about the future of emergency medicine. Both highlight the need for change within EDs and in wider health systems, and the power of emergency physicians to drive it. Skinner⁸ emphasises emergency physicians' skill as leaders and decision-makers, and leans into ED's place at the centre of the acute care system. She predicts an important role for emergency physicians in the development and ongoing coordination of a more community-based health system of tomorrow. Somewhat in contrast, Jerram,⁹ concerned that our overcrowded departments and broadening scope are preventing us from helping those who need us most, advocates for a narrowing of scope. He also reminds us that overtesting and low-value care contribute to ED overcrowding as well as patient harm. Not afraid to put his head above the parapet, he encourages us to think carefully about intergenerational equity: how should limited healthcare resources be allocated in the context of an ageing population, and what responsibilities does this place on emergency physicians? Fundamentally, both FACEM authors agree that we must maintain our mission of acute generalism, but be willing to radically adapt our systems and practice in order to best serve our communities and wider society.

Emergency medicine is sick, but the condition is treatable. Achieving a cure will require immediate decisive action, followed by a carefully considered long-term strategy. It will necessitate a keen eye for detail alongside an understanding of the big picture. It will call for the cultivation of strong relationships, as well as the willingness to advocate and put up a fight. In other words, it will demand the skills of an emergency physician.