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Evolution of the Literature Identifying Physicians' Roles in Leadership, Clinical Development, and Practice of the Subspecialty of Emergency Medical Services

Published online by Cambridge University Press:  25 March 2011

Michael G. Millin ,
Lawrence H. Brown ,
Catherine K. Craven ,
Seth C. Hawkins ,
David K. Tan ,
Gina M. Piazza ,
David C. Cone  and
Richard W. Sattin
Michael G. Millin*
Affiliation:
Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland USA
Lawrence H. Brown
Affiliation:
Anton Breinl Centre for Public Health and Tropical Medicine, James Cook University, Townsville, Queensland Australia
Catherine K. Craven
Affiliation:
Welch Medical Library, Johns Hopkins University, Baltimore, Maryland USA
Seth C. Hawkins
Affiliation:
Emergency Medical Care Program, Department of Health Sciences, Western Carolina University, Cullowhee, North Carolina USA
David K. Tan
Affiliation:
Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri USA
Gina M. Piazza
Affiliation:
Department of Emergency Medicine, Medical College of Georgia, Augusta, Georgia USA
David C. Cone
Affiliation:
Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut USA
Richard W. Sattin
Affiliation:
Department of Emergency Medicine, Medical College of Georgia, Augusta, Georgia USA
*
Correspondence: Michael G. Millin, MD, MPH Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimore, Maryland 21205 USA. E-mail: millin@jhmi.edu
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Abstract

Purpose: The 2007 Institute of Medicine report entitled Emergency Medical Services at the Crossroads identified a need for the establishment of physician subspecialty certification in emergency medical services (EMS). The purpose of this study was to identify and explore the evolution of publications that define the role of the physician in EMS systems in the United States.

Methods: Three comprehensive searches were undertaken to identify articles that define the physician's role in the leadership, clinical development, and practice of EMS. Independent reviewers then evaluated these articles to further determine whether the articles identified the physician's role in EMS. Then, identified articles were classified by the type of publication in order to evaluate the transition from a non-peer reviewed to peer-reviewed literature base and an analysis was performed on the differences in the growth between these two groups. In addition, for the peer-reviewed articles, an analysis was performed to identify the proportion of articles that were quantitative versus qualitative in nature.

Results: The comprehensive review identified 1,504 articles. Ninety articles were excluded due to lack of relevance to the US. The remaining 1,414 articles were reviewed, and 194 papers that address the physician's role within EMS systems were identified; 72 additional articles were identified by hand search of references for a total of 266 articles. The percentage of peer-reviewed articles has increased steadily over the past three decades. In addition, the percentage of quantitative articles increased from the first decade to the second and third decades.

Conclusions: This comprehensive review demonstrates that over the past 30 years an evidence base addressing the role of the physician in EMS has developed. This evidence base has steadily evolved to include a greater proportion of peer-reviewed, quantitative literature.

Keywords

emergency medical servicesevidence basedphysician's rolespecialties

Information

Type
Comprehensive Review
Information
Prehospital and Disaster Medicine , Volume 26 , Issue 1 , February 2011 , pp. 49 - 64
Copyright
Copyright Millin © World Association for Disaster and Emergency Medicine 2011

Introduction

In 2007, the Institute of Medicine report Emergency Medical Services at the Crossroads included a formal recommendation to establish physician subspecialty certification in Emergency Medical Services (EMS).1 This supported a similar call for subspecialization issued in the EMS Agenda for the Future 2 by the National Highway Traffic Safety Administration (NHTSA). To advance this process, in 2008, the National Association of EMS Physicians (NAEMSP) and the American College of Emergency Physicians (ACEP) supported a project to identify and quantify the scientific studies and publications that define the unique role of the physician in EMS.

The project was a component of an application submitted to the American Board of Medical Specialties (ABMS) to create a formal subspecialty certification in EMS. This application requires the demonstration of the scientific basis for the subspecialty.3 In addition to the ABMS requirement, identifying the nature of the science supporting the subspecialty of EMS lends credibility to the position that EMS medicine is a unique clinical entity requiring specialized expertise.

While there are many elements to the scientific basis of a medical specialty, it was the goal of this project to specifically examine the direct participation of physicians in the practice of EMS medicine. It was felt that this was important so as to determine the extent to which physicians have been directly involved with the growth and development of EMS. This article describes this project and reports its findings.

Methods

A comprehensive review based on literature identified through three expert searches executed by a professional clinical librarian was performed. The purpose of this review was to identify the literature that defines the physician's role in an EMS system.

Search Strategy

Standard keywords and keyword phrases used by EMS practitioners and researchers that represent primary EMS concepts were identified by surveying the study authors, a group composed of six emergency physicians, a paramedic, and a clinical librarian. All six of the physicians are actively involved in EMS medical direction and/or EMS research. In every case where an appropriate Medical Subject Heading (MeSH) term exists, the librarian then identified the formal MeSH controlled vocabulary terms used to index the literature representing each of these EMS concepts. Ultimately, a total of 27 search terms, including keywords and MeSH-controlled vocabulary terms were used to represent the conglomerate term “EMS” (Table 1). Within PubMed, these EMS keywords and MeSH terms were combined in three different search strategies to identify articles reporting the scientific evidence underpinning three aspects of the physician's role in EMS, specifically: (1) the physician as an EMS leader (Leader); (2) the physician's role in the clinical development of EMS (Clinical); and (3) the physician's role in the practice of EMS medicine (Practice) (Table 1). Although there was considerable overlap in the three search strategies, this approach was taken to ensure the broadest possible search covering all three of these aspects of the physician's role in EMS.

Table 1

Search strategies (EMS = emergency medical services)

The searches for Leader, Clinical, and Practice were performed on 14 June 2008, 27 August 2008, and 26 June 2008, respectively. All years in the PubMed database, up to the dates of the searches were included in the study.

Review Strategy

Two independent reviewers evaluated each citation in the three retrieved sets to identify and exclude any papers that actually did not address the role of the physician in the leadership, clinical development, and practice of EMS. Papers that were not relevant to the structure of EMS systems in the United States also were excluded, since EMS system design and the role of the physician within an EMS system may be different in the US compared with other countries. Any discrepancies between the two reviewers were resolved by the primary investigator.

After this initial screening, the references from the bibliographies of the articles retained were searched by hand by one investigator to identify additional papers that met the inclusion criteria. Potential articles were reviewed by a second investigator with discrepancies resolved by a third investigator.

Classification Strategy

All of the articles identified for inclusion were placed into one of three final data sets: (1) citations published in peer-reviewed journals; (2) citations published in non-peer-reviewed journals; and (3) professional society position statements or governmental reports. The determination that a journal was peer-reviewed or non-peer-reviewed was made by referring to Ulrich's Periodicals Directory.4 In cases for which it was not possible to determine if a journal was peer-reviewed or non-peer-reviewed using Ulrich, the publisher of the journal was contacted directly.

Subsequently, the three data sets were examined to determine changes in the amount of published articles within each set over time. Changes in the proportion of peer-reviewed verses non-peer reviewed articles were evaluated using the Chi-square test for linear-by-linear association, with articles analyzed in 10-year increments (1978–1987, 1988–1997, and 1998–2007). Since the review did not include the full year's worth of articles from 2008, that year was excluded from this analysis.

In regard to the peer-reviewed articles, an analysis was performed to identify the percentage of articles that were quantitative versus qualitative in nature. Articles were defined as quantitative if the authors used either descriptive or comparative statistical analysis in the paper. Articles were analyzed in 10-year increments (1978–1987, 1988–1997, and 1988–2007). As with the analysis on peer-reviewed versus non-peer-reviewed papers, articles from 2008 were not included in this analysis. Analysis to determine changes over time was done using Chi-square for linear-by-linear association.

Institutional Review

This study was determined by the Johns Hopkins University Institutional Review Board as not qualifying as human subjects research.

Results

The process of identifying and selecting articles for inclusion, from the initial search to the final three data sets, is diagrammed in Figure 1. A total of 1,504 articles were identified via the three independent searches: 1,006 articles in the Leader set; 444 articles in the Clinical set; and 54 articles in the Practice set. Ninety of these articles were excluded because the articles clearly pertained to international EMS systems and were not relevant to EMS systems within the US (e.g., “The emergency medical system in Japan” and “Profile of the prehospital system in Madagascar”). Of the remaining 1,414 citations, (950 Leader, 411 Clinical, 53 Practice), 1,220 subsequently were identified for exclusion, with 194 unique papers addressing the physician's role within an EMS system retained for the review. Using the technique to calculate concordance in review as described by Sackett et al,Reference Sackett, Haynes, Guyatt and Tugwell5 Kappa values for the inter-rater reliability for the three review subsets (Leader, Clinical, and Practice) were 0.240, 0.475, and 0.764, respectively. Hand searching the references of these 194 papers identified an additional 72 relevant articles, for a final data set of 266 unique papers.

Figure 1

Flow of articles from initial search to final data sets (EMS = emergency medical services)

In terms of the type of publication, 184 papers were published in peer-reviewed journalsReference Alicandro, Hollander, Henry, Sciammarella, Stapleton and Gentile6–Reference Poultan, Gutierrez and Schwabe189 (Appendix); 55 papers were published in non-peer-reviewed journals190–Reference Salomone244 (Table 2); and 27 were position statements or governmental reports2,245–270 (Table 3).

Table 2

Articles published in non-peer-reviewed journals

Table 3

Position statements/governmental reports

When evaluating the growth of published articles over time, the number of articles published in non-peer-reviewed journals and the number of position statements or governmental reports has remained relatively stable. The number of peer-reviewed publications, however, surged in the mid-1980s, and since, has remained relatively constant and greater than the number of articles published in non-peer reviewed journals (Figure 2). Furthermore, the proportion of articles published in peer-reviewed journals has been steadily increasing, from 72% for 1978–1987 to 77% for 1988–1997 and 80% for 1998–2007 (Table 4), although this does not achieve statistical significance (p = 0.271). In addition, the proportion of articles in the peer-reviewed set that are quantitative, increased from 31% for 1978–1987 to 51% for 1988–1997 and 36% for 1998–2007 (Table 5), although this increase also does not achieve statistical significance (p = 0.972).

Figure 2

Number of peer-reviewed, non-peer-reviewed, and position statements/governmental reports related to the physician's role in EMS, 1978 to 2008

Table 4

Growth of peer-reviewed articles compared to nonpeer reviewed articles

Table 5

Proportion of quantitative versus qualitative articles in the peer-reviewed set

Discussion

The purpose of this study was to categorize the literature that identifies the role of the physician in the subspecialty of EMS medicine. Emergency medical services systems have grown dramatically since the 1960s, and the field of EMS medicine has an expanding evidence base that guides direct patient care activities in the prehospital setting, as well as maximization of resource utilization through EMS system designs and operational methods. Although the evidence base for EMS medicine still is in its infancy, this scientific knowledge has been steadily increasing since the 1970s, with marked increases in clinical trials beginning in the 1990s.1

The modern specialty of EMS began after the publication in 1966 of Accidental Death and Disability: The Neglected Disease of Modern Society.271 This document identified the need for a new discipline in medicine that would address the care of sick and injured patients outside of the traditional hospital setting, and the efficient transportation of these patients to appropriate acute care centers. More recently, both the National EMS Agenda for the Future 2 and the Institute of Medicine Report on EMS1 have called for formal recognition of EMS as a physician subspecialty. While there is no clear definition on what defines a medical specialty, and no accepted number of published articles required to establish that a medical specialty has a unique scientific basis, the findings in this review demonstrate that, over the past 30 years, there has been a building and evolving scientific basis addressing the unique role of physicians in EMS medicine.

Although this study was not designed to draw exact scientific conclusions from the compiled manuscripts, it is evident that there are some common themes identified in these manuscripts. The aggregate review of these manuscripts demonstrates that physicians have had a positive effect on the quality of patient care delivered in the out-of-hospital environment and the development of the science of EMS. Physicians have been instrumental in pushing the boundaries of EMS as medical specialty, and therefore, the continuous improvement of patient care. The current data set, with increasing proportions of manuscripts that are quantitative/peer-reviewed articles, lends credence to the gross analysis that these manuscripts show that the drive for quality in EMS by physicians has largely been through the establishment of measurable standards and an increasing scientific basis. Therefore, the 266 papers identified through this review demonstrate that there is a unique and specific body of evidence addressing the role of physicians involved in EMS, and that this body of evidence has shown that physicians have had a positive effect on the growth of EMS.

Limitations

In an effort to focus specifically on articles that addressed the role of the physician in EMS, a search strategy was designed that would only capture articles that were catalogued with one of the following search terms: Director, Institutional Management Teams [MeSH], Physician's Role [MeSH], or Physician Executives [MeSH]. While this strategy may seem a bit narrow, it was intended that in an unbiased manner, articles be indentifed that specifically addressed the physician's role in EMS. Therefore, this data set did not capture certain relevant articles on the overall development of EMS as a clinical specialty of medicine. Importantly, the intent of this review was not to identify sentinel or important papers related to EMS, but rather, to identify articles specifically addressing the unique role of physicians in EMS medicine. Future research may be designed to identify those articles that are important to the overall growth of EMS.

This review is limited further by lack of agreement by study authors in what articles to include in the final data sets. While study authors largely agreed on which articles to include from the Practice set (Kappa statistic = 0.764), there was less agreement on articles to include from the Clinical set (Kappa statistic = 0.475), and even less agreement from the Leader set (Kappa statistic = 0.240). It is possible that the lack of agreement reflects some statistical error as the Leader set was the largest of the three sets, and the Practice set was the smallest of the three sets. However, it also is possible that this variance in agreement reflects the differences in the opinions of the study authors' interpretations of the physician's role in EMS based on the three sets. Study authors appear to agree on the physician's role with regards to the Practice of EMS medicine, and to some extent, on the physician's role in the clinical development of EMS medicine, yet they appear to disagree on the role of the physician as a Leader in EMS medicine. This variance in agreement may reflect that the unique clinical aspects of the practice of EMS medicine are well understood by the authors, but the physician's role as a leader is less well defined.

There likely are two reasons for the variance in study authors' agreement on what articles to include in the leader set. Both of these reasons speak to the variance in which EMS physicians are leaders in EMS. Emergency medical services physicians serve in many different capacities that range from pure clinical work providing patient care in the out-of-hospital environment, medical oversight of ancillary healthcare providers in fire/municipal/commercial EMS agencies, EMS system data analysis and research, and local/state/national EMS system development. Some EMS physicians serve in a capacity involving some or all of these roles. With the great variance in the ways that EMS physicians work, it is no wonder that there is variance in the interpretation of what articles to include in the leader set. In addition, there is variance even within the clinical aspects the physician's role in EMS. Depending on the local environment, the physician will have varying degrees of leadership responsibilities and authority. This variance also will lead to a variance in the interpretation of what articles to include in the leader set. Therefore, the variance in what articles to include in the leader set perhaps is not surprising given the vast array of EMS system designs in the US, and the accompanying variations in how physicians are incorporated into the administrative structures of those systems.

Lastly, the review was limited to articles relevant to US EMS systems. The purpose of this study was to identify the role of the physician within EMS systems in the US. To the knowledge of the authors, physician participation within EMS systems varies greatly across the world. Therefore, as this project was performed to identify the scientific nature of EMS medicine within the US, it was felt best to exclude articles that defined EMS medicine in other countries. While this technically limited the breadth of the data set, had articles from international EMS systems been included, the data set would have been confounded by the variance in the role of physicians in these systems. Further study into the role of physicians in EMS medicine outside of the US may be warranted.

Conclusions

This review demonstrates that over the past 30 years, there has been significant growth in the number of published articles identifying the unique role of the physician in EMS medicine, specifically with regards to roles in leadership, clinical development and practice. This growing body of evidence consistently is evolving to include increasing numbers of peer-reviewed/quantitative articles. Collectively, these articles lend credence to the scientific basis of the physician subspecialty of EMS medicine.

AppendixArticles published in peer-reviewed journals

Abbreviations:

EMS = emergency medical services

MeSH = Medical Subject Heading

Presentation

An abstract of this paper has been presented at the National Association of EMS Physicians 2009 annual meeting in Jacksonville, Florida.

Financial Support

The authors received no financial support in the development of this paper.

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Figure 0

Table 1 Search strategies (EMS = emergency medical services)

Figure 1

Figure 1 Flow of articles from initial search to final data sets (EMS = emergency medical services)

Figure 2

Table 2 Articles published in non-peer-reviewed journals

Figure 3

Table 3 Position statements/governmental reports

Figure 4

Figure 2 Number of peer-reviewed, non-peer-reviewed, and position statements/governmental reports related to the physician's role in EMS, 1978 to 2008

Figure 5

Table 4 Growth of peer-reviewed articles compared to nonpeer reviewed articles

Figure 6

Table 5 Proportion of quantitative versus qualitative articles in the peer-reviewed set

Figure 7

Appendix Articles published in peer-reviewed journals