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Long awaited residency program granted by Heather Woolwine Public Relations Fighting for the newly instituted emergency medicine residency program was like fighting for a patient’s life. Through all the stops and starts, and the undying will of the ER department, the new program’s heart now beats with a rhythm that embodies the confidence and dedication needed to ensure the program’s success in training high-quality emergency medicine physicians.   “One of my goals when I came here was to see an emergency medicine program happen at MUSC,” said Larry Raney, M.D., emergency medicine director. “In emergency medicine, we save lives on a daily basis, and we have a very good operation here. With national barometers that indicate performance, we are consistently above national averages. Our crew really came together to show what we’re capable of and I’m excited to see the program take off.”   Members of the ER phone in patient concerns, discuss treatments, and monitor patient vital signs. ER residents will soon share this busy environment when the first class arrives in the summer of 2007. The emergency medicine residency program will begin in July 2007 with its first  class of six physicians. By 2009, the program is expected to be full for the first time with 18 residents. Fifty percent of the residents’ training will take place outside the emergency room, in other areas of the hospital, as set by national standards.   The vast and complicated history of getting the program enacted at MUSC stems back to the 1970s.   According to a detailed account of the emergency room at MUSC through 1999, the former emergency services director, Ralph M. Shealy, M.D., noted the first ER was at Charleston County Hospital (known as Charleston Memorial Hospital). When Charleston County EMS began operations in 1973, County’s emergency room (ER) was the only dependable destination for ambulances. For this reason, it received almost all critical illnesses and trauma cases in the region without regard to social class or station.   The training of residents in emergency medicine began at County in 1976. Then the program was placed under the direction of the MUSC Department of Surgery, until the group believed that the program had a better chance of survival elsewhere. In 1977, the faculty and residents moved en masse to Richland Memorial Hospital in Columbia, know now as Palmetto Health Richland, where the program resides today.   MUSC offered no emergency services from that time until 1980, when a federal initiative to create a national trauma system made funds available to the states for the designation of trauma centers. In 1981, South Carolina DHEC designated three sites: MUSC, Richland Memorial, and the Greenville Hospital System. At MUSC, two rooms on the west corridor of the first floor (1-West) were designated for that purpose   By 1991, MUSC needed an access point for patients suffering from heart attacks who would benefit from early intervention by cardiology and cardiothoracic surgery. Waiting for referrals from doctors’ offices would no longer do. MUSC opened a chest pain center and it was the first site on campus to which a patient could self-refer without an appointment for emergent care. Later that year, the construction of the current facility was completed. In 1993, MUSC invested in creating a primary care network which had the capacity to provide care to a large population of local patients funded by managed care organizations.   MUSC did not have the capacity to provide acute unscheduled care for this target population at that time, so a system was created to provide unscheduled acute care to compete for these patients using methods that had proved successful in the private sector. A key feature was the use of faculty physicians for direct patient care.   Shealy wrote in an institutional report, “The challenge was to recruit full-time attending physicians with appropriate training, certification, and experience to replace a host of part-time providers whose primary interests lay elsewhere. This investment was essential to achieving consistent and predictable clinical practice. We needed to be sure that a standard product could be delivered at all times regardless of the clinical schedule.”   Dr. Larry Raney, left, and Chip Tinley, R.N., discuss a patient's chart during a busy afternoon in the ER. After many growing pains, the emergency department attempted to gain an emergency room residency program for MUSC in 2000. Shealy and two physicians resigned, disheartened by issues related to focusing the ER’s sights on a more academic path. Shealy’s disappointment was easy to understand when looking back on his writing, “Every attending physician in emergency medicine is at MUSC for one reason: we all want to be teachers; all want the twenty-third medical specialty of emergency medicine to be recognized as an integral part of this university … [and we] we were brought to this campus to create a clinical service. But from the beginning, we declared our commitment to work for an academic Department of Emergency Medicine and a residency program at MUSC.”   It was Raney's stewardship that enhanced MUSC’s effective clinical enterprise and put it on the path once again to employing an emergency medicine residency program. He set the stage by rearranging pay methods to accommodate academic activity on behalf of staff, changed the business model, and switched emergency services from a division of anesthesia within MUHA to its own division, thus opening themselves up for collaboration with the College of Medicine.   The biggest challenge that Raney and his colleagues faced in establishing the residency program was to first convince MUSC and the national emergency services Residency Review Commission (RRC) that an emergency medicine residency program at MUSC was necessary. An important step in gaining academic credibility was to place the division of emergency medicine in the department of medicine where mentoring and resources for academic development exist under the leadership of Jack Feussner, M.D., Department of Medicine chair. Once that was accomplished and after getting the green light for a residency, Raney hustled through sleepless weeks to crank out the 100-plus page program information form required for application. The second moment of truth came last summer when a consultant hired to determine the feasibility of an emergency medicine residency program at MUSC issued doubts about the group’s capability of launching such a program.   “He didn’t think the RRC would see either me (program chief) or Sam Kini (M.D., program director) as fit for our posts, as we don’t have a lot of academic publications out there,” Raney said. “However, we later found out that he was discounting our numerous speaking and lecture engagements. We were later informed by the RRC that speaking and teaching now count towards academic development, so in essence, he based his decision of us needing four to five more years to begin a program on some outdated information.”   By the end of September 2005, Raney and his colleagues were still expecting the worst, that their patient, the new program, wasn’t going to make it. Instead, they received a letter of clarification asking them to provide more detail on various items within their application. Raney and the others began to get excited. “We knew it had to be a good thing to not have been told no right off the bat,” he said.     On Feb. 20, the official word was given that the program could go forward. “Sam was giddy when we got the news. It’s safe to say we wanted to hire a sky-writer to announce it to the world,” Raney said. They received the official letter three weeks ago, just under the cut to participate in next year’s residency match programs throughout the nation.   “ One of the most attractive things about having an emergency residency program is the introduction of young, thirsty minds to the ER,” Raney said. “As with any residency, the residents will help with the chores and we’ll teach them so much when they’re here, but in addition, their presence will boost the academic level of the staff as well. Our staff members are incredibly experienced, but many of them have not forayed too far into academic development. By having this residency program, we’re making emergency medicine a more academic environment, which in turn can only be a good thing.”   “Emergency medicine is an important specialty and for any specialty to reach its full potential here at MUSC we believe it important to have an ACGME approved residency in that specialty,” said Jerry Reves, M.D., College of Medicine dean. “This will give the fine physicians who practice emergency medicine here at MUSC an opportunity to join the academic ranks of their colleagues in other specialties.”   Raney also discussed common misperceptions of emergency medicine rooted in history. In decades past, many physicians and medical academia felt that those physicians who chose to go into emergency medicine did so simply because they weren’t talented enough to practice medicine in other ways. Not the case today, according to Raney. He said that today's emergency medicine residency programs are some of the most competitive and sought after programs of study in the country. “There’s still some dissent, but the majority out there realize that these are smart people who didn’t pick emergency medicine because they couldn’t do anything else.”     It helps to get a residency program off the ground with the support of the powers that be, in this case, Reves and Feussner. Raney said that Reves was immediately receptive to the idea and saw it as an opportunity to mold emergency services at MUSC into more of an academic setting, and that Feussner saw it fit to “take the governor off the engine,” and let Raney and his colleagues run with the process.     In preparation for the program, Raney hired three new attending physicians who along with him and the current emergency room attending physicians, will serve as core faculty for the new residency program. All three new hires were students in MUSC’s COM. Now that Raney has accomplished a goal near to his heart since he arrived at MUSC, what does he see for the future of emergency medicine at MUSC? “I’d love to see an endowed chair in emergency medicine research. As of now, there are only five or six nationwide,” he said. “And a major renovation will come our way in the near future, thanks to a $10 million MUSC Board of Trustees commitment.”     Friday, May 5, 2006 Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Island papers at 849-1778, ext. 201.