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Emergency Medicine Exchange: Italy, the US and the Future

di Alexandra Asrow

Resident in Emergency Medicine (EM), in Chicago, Illinois (Usa), recentemente ospite della Scuola di specializzazione in Medicina di emergenza-urgenza dell’Università La Sapienza di Roma.

 

Cari saluti a tutti!

My name is Alexandra Asrow, and I am currently a “specializzando” or “resident” in Emergency Medicine (EM) in America, in Chicago, Illinois. Italy has long been close to my heart. In past years, I have been lucky enough to spend a semester in Bologna in the Erasmus program, and a year in Torino doing biology research. Once again, as part of my residency program (specializzazione), I was fortunate to be able to arrange and incorporate a month in Rome at La Sapienza working with the wonderful people at the Policlinico Umberto I.

We have spent the past four weeks exchanging information and sharing knowledge about residency, medical education, and EM in Italy and the US. I would like to share some of the information we have relayed with the members of SIMEU, and share some exciting possibilities for the future.

To begin, here is an overview of the medical education process in the US:

High school graduation

Followed by:

College (4 years) – may study any subject, must complete prerequisite courses (biology, math, chemistry, etc.) for “pre-medicine

Followed by:

Medical College (4 years) – 2 years didactics in classroom, 2 years rotating in clinics/hospitals in various specialties, choose your specialty at start of 4th year

Followed by:

Residency (3-4 years) – specific to specialty, varies by program

Obviously this system is different than the Italian system, in which “college” and “medical school” are combined into a 6-year university program. However, overall the number of years remains the same in the end at 11 with residency being 5 years long in Italy.

In the US, in order to obtain a spot for residency, there is a system called the “match.” It includes a series of applications, interviews, and each student creating a rank list of residency programs they like best. One very important day called “match day,” each medical student in the US (and international graduates hoping to do their residency in the US) receives notification of the program in which they have “matched” by the rank list matrix, and there is no option to change spots. Some are far from home, some not the favorite, and some don’t get a spot at all. There are currently 165 residency programs in the US with a total of 1.744 positions per year (each being 3-4 years total), and yet each year there are more applicants than positions. It is one of our fastest, if not the fastest growing specialty and gains popularity and competition every year.

Obviously this is quite different than the Italian residency system! I am very pleased, however, that the excitement and growth in EM has spread to Italy. Five years ago, Italy started 25 residency programs throughout the country with 2 positions per year, which will graduate their first residents this year. It turns out one of the few things in the US older than in Italy is Emergency Medicine! Our first residency program was founded in 1970, and one of the main differences we have discussed between residency programs in the US and Italy has much to do with age.

Based on experience, trial, and a lot of error, our system has become extremely standardized, with the ACGME (the Accreditation Council for Graduate Medical Education) providing extremely detailed rules and requirements for all residency programs and residents to maintain their status. Therefore, a general result of this is that all residents complete a certain number of hours, types of patients, critical care, percentages of pediatric patients (20%) and numbers of procedures amongst other things before completing their residency.

Alexandra Asrow con parte della équipe di Sala rossa del Policlinico Umberto I di Roma

As a slight tangent, beyond the differences in the education system, I believe an even more distinctive difference between Italian and US Emergency Medicine is the structure of the Emergency Department (ED) itself. My experience observing in the “Sala Rossa” at Policlinico Umberto 1° has been valuable in understanding this. I think these differences are reflected in what is included in our residency programs, which are illustrated below. The main difference is that in the US, the department is never divided into sections, even in the largest hospitals.

As the Emergency Physician, we are responsible for every patient that visits. This means we care for critically ill medical patients, surgical, trauma, pediatric, and pregnant patients. We deliver babies, we intubate, we do central lines, reduce fractures and dislocations, place splints, sutures, nasal packing, transvenous pacemakers, ultrasounds, I could go on. Basically, if it can come through the door, we have to be ready.

Obviously, if we need help, in many hospitals there are consultants available for every specialty. In some cases they may come to the ER to see the patient, take them to the operating room, evaluate them once they are admitted, or anything else required. This only occurs after the Emergency Physician has completed their complete workup and deemed it necessary.

However, in many hospitals, especially rural, there are no other doctors for long distances, and the hospital may not be fully equipped. If the patient needs something beyond our scope, we stabilize them to the extent of our capabilities, and work with the extensive emergency medical services systems and transport them elsewhere by ambulance or helicopter.

Now, to transport us back to the topic of medical education, I will share some specifics about my residency program, called the “Resurrection Emergency Medicine Residency Program.” If you are interested, you may visit our website at:

https://www.presencehealth.org/physicians/residency-programs/emergency-medicine/presence-resurrection-medical-center/welcome-director

In brief, we work at 7 different hospitals seeing different patient populations. Some have more elderly critical patients, some with severe trauma, some pediatric hospitals. In the ED we work 10 or 12-hour shifts, about 18 shifts per month. This varies when we are rotating in other specialties as below. We also have 5 hours of lectures weekly about various topics, monthly tests on these topics, and are required to create and present a certain number of presentations to present to our colleagues during these lectures throughout residency.

We complete the following months:

Emergency Department

20 months

Pediatric Emergency Department

3 months

Trauma (including inpatient/ICU)

2 months

Medical Intensive Care Unit

3 months

Surgical Intensive Care Unit

2 months

Pediatric Intensive Care Unit

1 month

Anesthesia

1 month

Obstetrics and Gynecology

1 month

Ultrasound/EMS

1 month

Toxicology

1 month

Administration

1 month

Radiology/Orthopedics

1 month

Infectious Disease

1 month

Elective

1 month (Mine spent in Italy!)

 

In addition, the following are numbers of different procedures required by the ACGME to graduate residency:

 

Procedure

Numbers

Adult medical resuscitation

45

Adult trauma resuscitation

35

Pediatric medical resuscitation

15

Pediatric trauma resuscitation

10

Cardiac pacing

6

Central venous access

20

Chest tubes

10

Cricothyrotomy

3

Dislocation reduction

10

Intubations

35

Pericardiocentesis

3

Procedural sedation

15

Vaginal delivery

10

Emergency department bedside ultrasound

*200 (in my program)

 

As if this weren’t enough, we receive evaluations for every shift we work in the ED, every procedure, and every rotation in another department. This is, again, based on milestones required by the ACGME and expected levels at various points. I could continue to outline infinitely more detail, but I am hopeful that the general picture is clear. Residency in the US is extremely demanding, and by way of this, hopefully produces incredible and capable young doctors.

After graduating residency, one becomes an “attending” physician, and may continue with a fellowship, or subspecialty of 2 years, or go on to a working position. There are different types of jobs including “academic,” meaning teaching students and residents and research, “community-based,” or combined.

Throughout this process there are a number of different very important and difficult exams. These include the USMLE (United States Medical Licensing Examination) “Step” exams 1-3, which are general and standardized for all medical students regardless of specialty, “In-service” exams each year of residency which are given to all residents in the particular specialty as comparison, and finally the written and oral board exams after residency is over to receive final licensure and board certification.

Personally, I am obviously interested both in education and International EM, specifically in Italy. This experience has been eye opening and fantastic, and I am looking into ways to continue communication with SIMEU and my colleagues in Rome in the future. I hope that this blog post has been educational and interesting for everyone. I also hope it has given readers some insight about our similarities and differences, and maybe spark some ideas for future projects.

I am looking into ways to start to provide more direct dialogue between residency programs and SIMEU with my own program, and hopefully the American College of Emergency Physicians (ACEP) International Section in some capacity in the future. I am hopeful that through everyone’s efforts and some hard work, we can continue to advance Emergency Medicine in Italy, and continue to develop and improve the residency programs here.

When I (hopefully!) graduate this June, I will be starting my new job in Springfield, Illinois, working in the ED, teaching students and residents, and hopefully continuing to develop EM in Italy! I am grateful for the openness and hospitality at Umberto 1° in Rome, special thanks to Dr. Giuliano Bertazzoni and his wonderful residents for all of their help. I hope for many returns! Thank you for your time reading this, and please feel free to contact me with any questions or comments.

Grazie mille!

-Alexandra Asrow

Lexie@alumni.brown.edu

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2 Responses to “Emergency Medicine Exchange: Italy, the US and the Future”

  1. admin_simeu Says:

    Thanks to Alexandra Asrow for her interesting post and her kindness. Hope to see her soon back to Italy! La redazione del blog Simeu

  2. roberto cosentini Says:

    Thanks Alexandra for sharing your experience across the Atlantic Sea!
    Your summary about US residency is very intersting and attractive.
    I hope our residents will have the chance to reach you in Springfield to spend some time with you, challenging they knowledge with your EM health system as you did with ours.
    thanks again
    roberto cosentini

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