Originally published in Synapse on April 17, 1980.
Dr. Nancy Gorham says she feels sad and angry. She says she “went through a terrible depression” after Dec. 5. Dr. Gorham is a junior resident in emergency medicine at San Francisco General Hospital (SFGH); which is to say she has been orphaned. As of Dec. 5, the emergency medicine residency at SFGH was “discontinued.”
According to Dr. H. Barrio Fairley, SFGH-based Associate Dean of the UCSF medical school, the decision to discontinue the one-and-a-half-year-old residency program was made when he met with SFGH Chief of Surgery Dr. Donald Trunkey, Acting Chief of Medicine, Dr. Melvin Cheitlin, Chief of Staff Dr. Donald Fink, and Chief of Pediatrics Dr. Moses Grossman.
Dr. Fairley said he also consulted with Dr. Julius Krevans, Dean of the UCSF medical school and Dr. Merle Sande the future SFGH Chief of Medicine.
None of the emergency medicine faculty residents, however, were present at the decisive meeting.
“I feel most angry that the meeting, was called without emergency medicine represented,” said Dr. Gorham. “It leaves you with a feeling of total helplessness.
“Certainly, we came here with the expectation that it would be a full two-year program. There was no expectation that UC would pull out.”
Limbo
While the four senior residents in the emergency medicine program will graduate virtually unscathed this summer, and the three interns have made plans to transfer to other emergency medicine residencies, Gorham says she and the three other junior residents feel somewhat in limbo.
According to Dr. Fairley, UCSF has arranged for these residents to complete their training next year with six months of rotations at SFGH and six months in the emergency room at Oakland’s Highland Hospital.
Dr. Fairley says that UCSF has agreed to relieve the City of San Francisco of half the residents’ salaries when they are practicing through the emergency medicine residency at Highland.
But according to Dr. Gorham, the junior residents are still nervous. They aren’t sure, she says, whether after this fragmented training they will ultimately be considered board eligible in their specialty and graduates of an accredited program.
Meanwhile, says Dr. Gorham, the lame duck emergency medicine residents are being treated, “as if we are less competent, less intelligent, less astute, less dedicated...like second-class doctors” by some UCSF and surgery residents.
Resignations
The decision to halt the residency program, according to Dr. Fairley, was triggered by the November resignations of Dr. William Teufel, Director of the emergency room and founder of the residency program, and Dr. Constance Wofsy, Associate Director of the emergency room.
Both Dr. Teufel and Dr. Wofsy planned to leave in the summer; Teufel for “personal reasons” and Wofsy to pursue a fellowship in infectious disease.
These resignations, said Fairley, left the emergency medicine residency with only one-and-a-half full-time faculty members.
“So we had two options,” he said, “one was to put a hold on recruiting for the residency program, the other was to try to keep recruiting and beef up the staff.”
With the “match date” for soliciting new residents looming on Dec. 14, Dr. Fairley and the assembled chiefs decided not to recruit residents for the coming year and not to replace the emergency medicine faculty, effectively ending the residency program and temporarily returning responsibility for the emergency room to its traditional corner — the Department of Surgery.
While Dr. Fairley says that without the resignations the emergency medicine residency would have been left to “trickle along,” he stresses that “it would be wrong to say that (the resignations) were the sole reason for the thing closing.
“It was the precipitating factor to look very closely at the program,” said Dr. Fairley. “And when we looked at it, we saw it was not very strong.”
Dr. Fairley claims that the emergency medicine residency program was “incompletely and inadequately conceived,” without official UC approval, had “no adequately planned educational program,” and was run on a “shoestring budget” that was about to break.
And given the financial constraints imposed on both UCSF and the city by Proposition 13, said Dr. Fairley, the program’s future did not look bright.
Flourish or Die
That the residency program was “in trouble” and “failed to flourish,” said Dr. Fairley, is indicated by the report of the Liaison Residency Endorsement Committee which withheld approval for the program this March.
“The major deficiencies” in the residency program, wrote the committee, “are lack of institutional support, inadequate staff, inadequate resident supervision, and inadequate emergency conferences.”
Though the residency program will retain its “approved” status until this summer, it is not officially approved beyond then.
Though various emergency medicine faculty and residents admit that their program “had some problems,” they blame both the bulk of these problems and their program’s curtailment on the Liaison Committee’s premier criticism: lack of institutional support.
The emergency medicine residency, they agree, was hampered by the fact that it received no money directly from the university but was forced to “trickle along” with city funds for the faculty and resident salaries and a small Health, Education and Welfare Department grant (a hand-me-down from the Department of Surgery) for the clerical staff.
In Dr. Teufel’s opinion, the crisis in emergency medicine came in September of 1979 when the grant for the clerical workers began to run out, and Dr. Teufel asked Dr. Fairley for funds. Regarding the issue of UC approval of the program, Dr. Teufel claims that he did not know that Dr. Krevans’ approval was required.
Dr. Teufel had, in fact, received letters from Dr. Walter Coulson, then Associate Dean of the medical school at SFGH, in both 1977 and 1979 extending “formal support” to the residency “on behalf of the University of California.”
“It seems to me that if the university and the administration upstairs were interested in continuing the program, they would have corrected whatever deficiencies our program had rather than just cancel it,” said senior resident Bob Banka.
“There is no question in my mind that that could easily have been done.”
Preconceived Notions
Dr. Teufel claims, however, that those responsible for cancelling the program, with the exception of Dr. Fairley, were ignorant of the program itself.
“We were judged in a vacuum,” said Dr. Teufel. “The decision to end the program was based on their preconceived notions of the field, not the facts.”
According to Dr. Teufel, the emergency medicine residency was ended because the university and the SFGH department chiefs failed to support the concept of emergency medicine.
And as far as Dr. Teufel and others in his program are concerned, a lack of commitment to emergency medicine shows a lack of commitment to primary care.
Though emergency medicine was only officially recognized as a medical specialty last September, there are currently about 50 emergency medicine residencies in the country.
Emergency medicine, however, remains controversial, especially in academia.
Like family medicine, another embattled new primary care specialty, emergency medicine lacks a developed body of research which offers universities the promise of prestige and grant money.
Emergency medicine proponents argue however, that the public needs broadly trained emergency physicians who are willing to staff hospital emergency rooms on a fulltime basis.
In California alone, says Dr. Karl Mangold, a spokesman for emergency physicians, there are about 11,000,000 emergency room visits a year.
So, controversy at SFGH boils down to whether the emergency medicine residency was discontinued due to its “failure to flourish” or whether the program failed to flourish because of UCSF opposition to emergency medicine.
Dean Krevans was unavailable for comment, but Synapse interviewed Dr. Fairley and all of the other SFGH chiefs who participated in closing the residency.
According to both Drs. Fairley and Trunkey, an emergency medicine residency program wasn’t particularly what was wanted when Dr. Teufel was hired in 1976 to direct the emergency room.
According to Trunkey, the emergency room had previously been “run by residents” without adequate supervision, and Dr. Teufel was hired to provide a staff of attending physicians who were dedicated to the emergency room and would work there on a full-time basis.
The residency program was a “perk” said Trunkey, to get Dr. Teufel on board and keep him.
Glorified Paramedics
Though Dr. Trunkey says he supported the residency program “from the start” he also says that he has reservations about emergency medicine.
Trunkey says that the country needs fewer emergency physicians — and emergency rooms — than emergency medicine proponents claim.
He also claims that surgeons are better qualified than emergency physicians, who he calls “glorified paramedics,” to handle trauma cases.
According to Trunkey, 80 per cent of the cases coming into emergency rooms are primary care rather than “bona-fide emergencies.”
“If emergency physicians want to work on the primary care side, fine,” he says.
Dr. Cheitlin, however, says that most internists, including Dr. Sande who will soon become Chief of Medicine at SFGH, feel that internists are better qualified than emergency physicians to take care of these primary care patients.
Dr. Fink, who is a family medicine physician, says he is not as enthusiastic about emergency medicine as he is about family medicine because he believes that these primary care patients should not be seen in emergency rooms at all but seen by family practice physicians or internists in more traditional settings.
Dr. Grossman said only that while he believes there is a need for physicians to work full time in emergency rooms, he doesn’t know what their training should be.
Dr. Fairley stated that while he agrees that “there is a market for emergency room physicians in the community” it is not clear to him that “there is some sort of obligation on the part of the medical schools all to have a department of emergency medicine.”
Deju Vu
According to Dr. Fairley, the department chiefs at SFGH along with representatives from the city, hospital administration, residents, nursing staff and emergency medicine faculty are already meeting to plan the future of the emergency room.
Whether or not the emergency medicine residency is revived, says Dr. Fairley, will depend largely upon the wishes of the new director of the emergency room.
Fairley and some of the others recognize, however, that an emergency medicine residency might again turn out to be the needed “perk” to hire an emergency room director.
“I feel very strongly that in the next three years we’ll find ourselves right back where we were a year ago,” says Dr. Trunkey.
