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Emergency Medicine Around the World: Analysis of the 2019 American College of Emergency Physicians International Ambassador Country Reports

Objective The specialty of emergency medicine and recognition of the need for emergency care continue to grow globally. The specialty and emergency care systems vary according to context. This study characterizes the specialty of emergency medicine around the world, trends according to region and income level, and challenges for the specialty. Methods We distributed a 56‐question electronic survey to all members of the American College of Emergency Physicians International Ambassador Program between March 2019 and January 2020. The Ambassador Program leadership designed the survey covering specialty recognition, workforce, system components, and emergency medicine training. We analyzed results by country and in aggregate using SAS software (SAS Institute Inc). We tested the associations between World Bank income group and number of emergency medicine residency‐trained physicians (RTPs) and emergency medicine specialty recognition using non‐parametric Fisher's exact testing. We performed inductive coding of qualitative data for themes. Results Sixty‐three out of 78 countries’ teams (80%) responded to the survey. Response countries represented roughly 67% of the world's population and included countries in all World Bank income groups. Fifty‐four countries (86%) recognized emergency medicine as a specialty. Ten (16%) had no emergency medicine residency programs, and 19 (30%) had only one. Eight (11%) reported having no emergency medicine RTPs and 30 (48%) had <100. Fifty‐seven (90%) had an emergency medical services (EMS) system, and 52 (83%) had an emergency access number. Higher country income was associated with a higher number of emergency medicine RTPs per capita (P = 0.02). Only 6 countries (8%) had >5 emergency medicine RTPs per 100,000 population, all high income. All 5 low‐income countries in the sample had <2 emergency medicine RTPs per 100,000 population. Challenges in emergency medicine development included lack of resources (38%), burnout and poor working conditions (31%), and low salaries (23%). Conclusions Most surveyed countries recognized emergency medicine as a specialty. However, numbers of emergency medicine RTPs were small, particularly in lower income countries. Most surveyed countries reported an EMS system and emergency access number. Lack of resources, burnout, and poor pay were major threats to emergency medicine growth.


Background
Emergency medicine emerged as a specialty in the 1960s and 1970s in response to the need for high-quality, expedient emergency care of patients arriving to the hospital with time-sensitive complaints. 1 Emergency medicine has been shown to improve the care and outcomes of patients with emergent complaints. [2][3][4] In 2007, the World Health Assembly Resolution 60.22 called for the involvement of ministries of health in the review and strengthening of trauma and emergency care, 5 and in 2019 the World Health Assembly Resolution 72. 16

"Emergency
Care Systems for Universal Health Coverage" identified emergency care as a critical component of the health system. 6 The first countries to recognize emergency medicine as a specialty include, but are not limited to, the creation of emergency medicine residency programs, board certification, specialty associations, peerreviewed journals, clinical guidelines, and subspecialties. 10 In addition to country-specific developments, regional and international emergency medicine societies, universities, and international development organizations have been important catalysts of emergency medicine development.

Importance
Despite the growing presence of emergency medicine, few studies have defined the structure of emergency medicine systems worldwide or compared the scope and availability of the specialty across regions.
To our knowledge, no comprehensive overviews of global emergency medicine have been published in almost a decade.

Objective of this study
The objective of this study was to characterize the current state of emergency medicine development around the world.

Design
This study was a descriptive, cross-sectional survey conducted by

Survey instrument development
The Ambassador Program leadership designed the survey tool with input collected from program members during the annual meeting. 12,13 The survey contained 56 questions covering categories including recognition of emergency medicine as a specialty, estimated num-

Other data sources
We used national population statistics from the United Nations Statistics Division's Demographic Statistics Database based on data from either 2019 or the next closest preceding year. 14

Data analysis
We graphed the recognition of emergency medicine as a specialty We analyzed free text responses to the question about perceived threats to emergency medicine development using inductive coding.
Two coders reviewed responses individually and each developed preliminary codes. The coders worked together to assess each code for clarity and application to different countries and developed a single code book. Each coder then assigned codes from the shared code book.
A senior author served as arbitrator for discrepancies between the coders and recorded code frequencies.
We conducted all analyses using SAS (version 9.4M6, SAS Institute Inc).

F I G U R E 1
Recognition of emergency medicine specialty: Of 63 countries in the 2019 American College of Emergency Physicians Country Report Compilation, 54 (86%) recognized emergency medicine as a specialty (blue) and 9 (14%) did not (orange)

RESULTS
Sixty-three of the 78 ACEP International Ambassador delegations completed a country report, for a response rate of 80% ( Figure 1).
Individual responses can be found on the ACEP International Ambassador website. 17 Table 1). There were a reported 65,097 emergency medicine RTPs around the globe, with more than half (nearly 36,000) in the United States ( Figure 2). Nearly half of responding countries have fewer than 100 emergency medicine RTPs (30; 48%) ( Figure 3, Table 2). Emergency medicine RTPs appear to be concentrated in urban areas ( Table 2). The higher income group was associated with a higher rate of recognition of emergency medicine as a specialty (P = 0.02) ( Table 2). Although some upper-middle income and lower-middle income countries had 2-5 emergency medicine RTPs per 100,000 population, the majority had <2 emergency medicine RTPs per 100,000 population. All low-income countries reported <2 RTPs per 100,000 population (Table 2).
As of 2019, an estimated 18,236 physicians were in training to become emergency medicine RTPs. However, the majority of responding countries had 10 or fewer emergency medicine residency programs, with 10 countries (16%) having none ( Figure 4). Nearly half of responding countries provide emergency medicine board certification (30; 48%). Among emergency medicine fellowships offered, pediatrics (13; 21%), ultrasound (11; 18%), and critical care (10; 16%) were the most common, though most countries did not have any (41; 66%) ( Table 3). Procedures in the scope of practice of emergency medicine RTPs included in the survey were practiced by emergency medicine RTPs in 64% to 88% of countries in the sample (Table 4) Table 4).  Column percentages provided in parenthesis.  Free text responses about threats to emergency medicine development were coded into themes, which were grouped into 12 main categories. The most common were limited economic resources in the health system (n = 20; 38%), burnout and poor working conditions (n = 16; 31%), low salaries (n = 12; 23%), and governmental mismanagement (n = 11; 21%) ( Table 6).

LIMITATIONS
This study provides an overview of emergency medicine around the world, though with important limitations. The data for each country were based on descriptions by the respondents rather than systematic measurements because these statistics are not available for most

DISCUSSION
Emergency medicine is entering its sixth decade as an independent medical specialty and continues to expand globally. emergency medicine recognition as a specialty grew from a handful of countries in the 1970s, to 41 countries in 2000, 18  Privatization of emergency care 3 6% Physician "brain drain" 1 2% the low-income group-were more likely to lack an emergency access phone number and to lack certain procedures in the scope of practice of emergency medicine RTPs (lumbar puncture, central line placement, procedural sedation, pericardiocentesis, and cardiac pacing). Sampling may be the most likely explanation, because our sample had only 5 low-income countries, which perhaps were more advanced in emergency medicine development than most other low-income countries and more likely to have had connections in international emergency medicine, such as the ACEP Ambassador required to be in our study.
The most common threat to the growth of emergency medicine reported was limited economic resources in the health system. This is not surprising, given the well-known global inequity in health care resources, despite significant gains in the last few decades. 20 The next most reported threats were burnout and poor working conditions, especially related to scheduling and dysfunctional processes at work.
EDs can be stressful environments, and there is a growing recognition of the need for wellness curricula and support systems for emergency medicine RTPs. 21,22 Beyond empowering individuals, scheduling and ED process improvement could improve the well-being of ED personnel. The third most common threat reported was low salaries, lead-