An insider perspective on residency training in the UK versus the USA.
The first patient history I ever took was from a wee Scottish man while studying medicine at the University of Edinburgh. Moving from whiskey to tea, I drifted south to the bright lights of London and completed my first two years of training. Now as an Emergency Medicine (EM) resident on the south side of Chicago, I transition from tea to coffee. The UK and the USA are fundamentally similar in their perception and utilization of the emergency department (ED) and the emergency physician. However further examination reveals that the two countries are indeed ‘‘divided by a common language’’. I am not just referring to the name Accident and Emergency (A&E) vs Emergency Room (ER)! There are transatlantic differences both in training organization and emergency health care systems.
EM is a relatively new specialty in both countries. In 1968, a group of eight US physicians formed the American College of Emergency Physicians (ACEP). The goal was to provide quality emergency care by education, structure and standards for the new “emergency physicians.”. In the UK in 1952 Mr. Maurice Ellis was appointed as the first consultant in EM at Leeds General Infirmary. Mr. Maurice Ellis also holds the distinction of being the first president of the Casualty Surgeons Association, which was established in 1967.
In both countries, the function of the Emergency department is, to stabilize the acutely ill patients, to triage patients and to provide a safety net for patients with primary care issues. However, development of EM in the UK is very different from its European neighbors. The “Franco-German model” places the clinical entity of EM exclusively in the prehospital setting. Inside the hospital, EM is considered an interdisciplinary activity that does not require specialty status. Barring the UK, the equivalent of an ED, similar to the US, does not exist in Europe.
Although there are significant differences in the perception of EM and system organization, the patient population and ED workload has been shown to be remarkably similar in both countries. It is, however, important to mention that there are two significant differences namely the complicated issue of health care payment and the legalization of firearms, which in my opinion do have an effect on the pathology experienced. The abundance of primary care provision in the UK does increase the likelihood of direct hospital admissions, and is effective in bringing to light medical emergencies earlier. In contrast, there is an increasing amount of primary care provision in the ED across the US, which may decrease average acuity of patient encounters. However, the lack of early intervention can contribute to the severity of illness seen.
In system organization there is a substantial difference in physician involvement of pre-hospital medical care. In the US, the participation of full time specialist emergency medical services (EMS) has been crucial to the development of this field and the development of innovative research. This is further illustrated in that, the American Board of Emergency Medicine (ABEM) has newly approved the EMS / pre-hospital fellowship. The UK also developed some of the earliest initiatives involving doctors in pre-hospital care and developed the field provision of advanced life support skills. The county of Derby introduced an accident flying squad as early as 1955. However medical involvement in pre-hospital care in the UK has been limited and is largely on a voluntary and informal basis. The US recognizes pre-hospital care as a crucial part of any EM physician’s training and the incorporation of this into US residency programs has become a substantial part of the resident training experience.
EM training in the UK and US are structured in very different ways. EM residencies in the US can be three or four years in length, depending on the institution. At the end of which, an EM residency program director certifies completion of training and a trainee sits for the ABEM certification exam. After residency completion, a number of fellowships are available for EM graduates including EMS, research, toxicology, global health, palliative care, hyperbaric medicine, sports medicine, ultrasound, pediatric emergency medicine, and critical care. In the UK, EM trainees enter specialty training after five years of medical school and two years of foundation training. Foundation training is compulsory for all medical school graduates, and structurally is equivalent to intern/resident year in the US. Trainees split their time equally between medical and surgical specialties, the aim of which is to give a broad overview of practicing in different fields while gaining competency in core clinical skills. Those wishing to pursue a career in emergency medicine must then complete a two-year core-training program (Acute Care Common Stem) during which doctors complete training in anesthesia, acute medicine, intensive care, and EM. In the third year, the trainee learns about EM with a pediatric focus and musculoskeletal EM. They must also pass the Membership of the College of Emergency Medicine (MCEM) examination, which would be the US equivalent to the inservice training exam. Trainees will then go onto further specialist training which lasts an additional 3 years. Completion of clinical training is followed by the final examination, namely the Fellowship of the College of Emergency Medicine (FCEM) must be passed (equivalent to the boards ABEM written certification exam). Upon completion of training the doctor will be eligible for entry on the GMC Specialist Register and allowed to apply for a post as a Consultant in Emergency Medicine. This brings EM residency training after medical school to a total of eight years. These additional years of UK post graduate training translate to enhanced clinical experience. The average American trainee sees 4500 patients in training, compared to 12000 in the UK8. A similar pattern is likely to translate to procedural experience8 although exact figures have not been extrapolated. It is important to highlight that although post medical school training is significantly longer in the UK, this is due to the fact that UK residents do not complete an undergraduate degree prior to attending medical school. Thus the average age of completion of training in both countries is around 30 years.
Supervision is a key component of resident training. In the US the ED is staffed 24 hours a day with a consultant level physician who works in the department and sees patients alongside the resident to provide on-site support as needed. The largest obstacle in the UK is lack of supervision from senior medical staff, including consultants. In the UK, some supervisory responsibility has fallen on the registrars and staff grade doctors, who are invaluable in sorting out the intricacies of the NHS system. Although independence is beneficial in developing autonomous practice patterns later in ones training, in early training supervision provides an incredible amount of informal education to the resident.
The core curriculum for training in the US and the UK are similar, with a strong emphasis on out of department critical care training (Anesthesia, Acute medicine, intensive care and trauma surgery) in the earlier years. As the trainee progresses in both systems a greater amount of time is spent in the ED. A vast majority of trainees in both countries spend time in more than one institution, in acknowledgement of the benefits of varied training environments. Didactic curricula in both systems have similar requirements, with weekly-protected conference time, journal clubs, scholarly projects and peer review being mandatory educational components.
In recent years regulatory bodies in both countries have decreased duty hours. In the UK the European working time directive was made law in 1993. This has lead to a reduction of duty hours to 48 hrs per week in 2009. The objective of this directive is to increase health and safety in the workplace, although decreased duty hours do help decrease a trainees mental anguish, the training system in the UK may negate this positive effect. A study by Whitely et al in 1994 showed that physicians in the UK reported significantly higher levels of stress and depression than their colleagues in the US, Australia and Asia. They hypothesize that this is because, senior registrars in the UK, who are still in training, are expected to teach, conduct research, and acquire management skills so that they can obtain desirable consultant appointments.
Luckily for me, the transition to the US has not substantially prolonged my training. I do feel strongly that as I develope a taste for bagels and give up crumpets, my training is not adversely affected by the move. As the US adopts working hour restrictions it will be interesting to see if there is an impact on training length, structure of the undergraduate training model and the financial concerns of trainees. The advancement of EM in the US is exciting for my pursuit of an academic career, without the logistical service related constraints of the National Health Service (NHS). Other than my confusion as to what football really is and subsequent deficits in taking a sports related history, my experience leads me to believe that both systems would have adequately prepared me to be a competent emergency physician.
- Hoffman GL, Bock BF, Gallagher EJ, Markovchick VJ, Ham HP, Munger BS. Report of the Task Force on Residency Training Information, American Board of Emergency Medicine. Annals of Emergency Medicine. 1998; 31:5; 608-625.
- McHugh, D., & Driscoll, P. (1999). Accident and emergency medicine in the United Kingdom. Annals of emergency medicine , 33 (6), 702-9.
- Maurice Ellis Award http://www.collemergencymed.ac.uk/temp/1026-cec_maurice_ellis_info.pdf
- Dykstra, E. (1997). International models for the practice of emergency care. The American journal of emergency medicine , 15 (2), 208-9.
- Williams, M. (1991). Emergency department workload–a transatlantic comparison. The Journal of emergency medicine , 9 (6), 411-6.
- Steinbrook, R. (1996). The role of the emergency department. The New England journal of medicine , 334 (10), 657-8.
- Mitchell, R., Brady, W., Guly, U., Pirrallo, R., & Robertson, C. (1997). Comparison of two emergency response systems and their effect on survival from out of hospital cardiac arrest. Resuscitation , 35 (3), 225-9.
- J P Nicholl, J. E. (1995). Effects of London helicopter emergency medical service on survival after trauma. British Medical Journal , 311, 217-22.
- Johnson, G. (1997). Medical involvement in prehospital care–a transatlantic comparison. Journal of accident & emergency medicine , 14 (4), 215-8.
- Wyatt, J., & Weber, J. (1998). A transatlantic comparison of training in emergency medicine. Journal of accident & emergency medicine , 15 (3), 175-80.
- Smith, J., Tevis, B., & Murali, K. (2005). Commentary from the front lines: American physician assistants working in a United Kingdom emergency department. Emergency Medicine Journal , 22 (5), 322-324.
- Rodenberg, H. (1996). Education in accident and emergency medicine for senior house officers: review and recommendations. Journal of accident & emergency medicine , 13 (4), 238-42.
- Pickersgill, T. (2001). The European working time directive for doctors in training. BMJ (Clinical research ed) , 323 (7324), 1266.
- Whitley, T., Allison, E., Gallery, M., Cockington, R., Gaudry, P., Heyworth, J., et al. (1994). Work-related stress and depression among practicing emergency physicians: an international study. Annals of emergency medicine , 23 (5), 1068-71.