DALLAS, Aug. 16, 2068 —“Good morning, Mr. Smith,” the nursing home’s artificial intelligence bot chimes. “Your heart rate and respiratory rate have been trending upwards overnight. I also noticed that you were coughing and your oxygen levels are a bit low. Would you like me to call the ED?”
A moment later, the hologram of an emergency physician appears. “Place the auscultation sticker on your back. It sounds like you have some fluid in your lungs, which could be secondary to a variety of conditions. You don’t look so hot, and you’re 72, so I think you should come in for a 3-D ultrasound and possibly some IV antibiotics.”
Emergency medicine has come a long way since ACEP was founded in 1968, from the first training program at the University of Cincinnati in 1970 to the founding of the Emergency Medicine Residents’ Association (EMRA) in 1974 to finally being recognized as the 23rd medical specialty by the American Board of Medical Specialties (ABMS) in 1979. Fifty years later, TV shows like “M*A*S*H” and “ER” have been produced, EMTALA and the prudent layperson standard have been enacted, and more than 140 million patients seek care from us annually.
Our nation has gone from dermatologists treating our sickest and most vulnerable patients in emergency rooms to specialist emergency physicians providing care in sophisticated departments. We’ve transformed America’s acute care system. However, as the residents who lead EMRA, it’s our job to imagine and prepare for the future. Fifty years from now, emergency medicine will be as different from today’s specialty as we are currently from our 1968 roots.
By the time Mr. Smith arrives at his local freestanding emergency department, his vitals have been uploaded by EMS, he has been preregistered, and his copay has been automatically deducted from his virtual wallet. He skips the waiting room, and the Internet of Health Care Things–enabled ultrasound rolls itself to his stretcher. The operational software has used his transport time to preschedule an appointment with the ED ultrasound technician. Twenty minutes later, Dr. Casillas, his board-certified emergency physician, sits down on Mr. Smith’s bed and holds his hand as she delivers the difficult news of a new lung mass and likely malignant effusion. At the same time, a virtual natural language processing scribe documents their conversation, codes the encounter, submits it to a national clearinghouse for reimbursement, and prompts her to place orders that had been previously placed for patients with similar presentations.
Dr. Casillas is a first-generation American who might not have had the opportunity to attend medical school in the 20th century, but by 2040, medical school had become significantly more affordable by shortening the time spent to 2.5 years and through funding from local counties and states to produce physicians who would serve their communities. Residency programs had also dramatically changed, transitioning from time-based to competency-based curricula, resulting in training lasting a variable number of years. Though the news Dr. Casillas delivers is heartbreaking, it is another example of the human connections made and compassionate care provided every day in emergency departments around the world.
In our imagined future, emergency departments have changed significantly since 2018. Technological advances like artificial intelligence (AI), remote patient monitoring, and telemedicine have increased access to care (particularly for underserved patients); allowed for earlier detection of life-threatening illnesses; and led to more precise triaging of patients before arriving at the emergency department. This has allowed emergency departments to anticipate and prepare for most patient arrivals and for board-certified emergency physicians to perform medical screening exams remotely and schedule patients to see their primary care physician or a subspecialist if more suitable. The reimbursement landscape and the business model of emergency medicine have finally adapted to the world of value-based care, and emergency departments are actually being reimbursed for sending lower-acuity patients to primary care physicians and subspecialists.
Perhaps the biggest change has been the elimination of most inpatient general medicine beds in America. Based upon each patient’s individual pharmacogenetic profile, robots start IVs, administer medications, and draw blood work at home, then drones transport these samples to labs for analysis. Due to physicians being able to remotely monitor patients’ vital signs and clinical status, the need to admit patients has plummeted. This has resulted in the majority of America’s acute care hospitals being closed. However, the need for emergency physicians has only grown, with micro-hospitals and freestanding emergency departments popping up from coast to coast, driven by the need for every community to have access to the acute care system as well as a desire to have a highly trained diagnostician physically evaluate patients in an increasingly digitized world.
A few hours later, Mr. Smith’s clinical status starts to decline. He becomes more hypoxemic and tachypneic. The smart ultrasound wheels itself back to meet Mr. Smith in the resuscitation bay, and the AI software notices a dilated right ventricle with reduced tricuspid annular plane systolic excursion (TAPSE) consistent with a pulmonary embolism (PE). Dr. Casillas checks his advance directive through the national next-generation health information exchange prior to intubation and alerts his family members who had subscribed to his real-time care feed. The hype of medical informatics has been realized as patients’ social, wearable, clinical, and genomic data are finally integrated into electronic medical records. A few minutes later he codes, and Dr. Casillas initiates extracorporeal membrane oxygenation (ECMO) and pushes tissue plasminogen activator nanobots, which have replaced the need for intravenous thrombolytics and catheter-directed thrombolysis. Initiating ECMO on a 72-year-old had become routine since the mid-2030s, when life expectancy surpassed 100. The AI resource allocation software then notices that, given his need for dedicated PE and ECMO teams, as well as local bed availability and risk-adjusted patient outcomes data, it would be best to transfer Mr. Smith to a hospital 90 miles away, bypassing three local centers. A minute later, he is loaded into an ICU drone equipped with tele-ICU capabilities and a midlevel critical care proceduralist, and he is whisked away. Because of the efficiencies of transferring patients to the nearest open bed available with appropriate resources rather than the closest hospital or the hospital that just so happened to be connected to the emergency department, the word “boarding” has been relegated to “back in my day” stories.
This futuristic thought experiment highlights two unique business models: micro-hospitals and hyper-acute specialty hospitals. In the emergency medicine of tomorrow, the latter, generally one every 100 miles, have been formed because in addition to the economies of scale within larger centers, a growing body of evidence had shown that high-volume centers, whether they be performing coronary artery bypass grafting or delivering ICU care, perform far better than lower-volume centers in terms of patient outcomes. A mix of large academic centers and corporations raced to consolidate the hospital market in the 2030s and created these 5,000-bed megaplexes of health care, just as Walmart and Amazon had done in the retail space during the early 2000s. Americans still needed access to acute care within a reasonable distance from their homes, and so the micro-hospital was born. Part freestanding emergency department with resuscitation bays and imaging in-house, part observation unit, and part heliport to efficiently ferry critical patients in specially made ICU drones to the specialty hyper-acute hospitals, these centers have proliferated, with emergency physicians at the helm.
While our specialty will evolve dramatically over the next 50 years, we believe the need for emergency physicians will only continue to grow. Tomorrow’s emergency physicians will build upon the giants who founded emergency medicine by being diagnosticians who can make sense of all the noise generated from enhanced triaging and remote patient monitoring, availabalists who see patients 24-7-365, resuscitationists who bring people back from death’s doorstep, and dispositionists who quarterback care in an increasingly hyper-specialized system. Most important, in an ever-virtualized world, they’ll serve as the humanists who actually take a few minutes to sit down and talk to their patients, bringing an element of sanity to the chaos of 2068.
NOTE: The views represented in this futuristic thought experiment solely belong to the authors and do not represent those of EMRA.
Dr. Maniya is the President of EMRA and a resident at The Mount Sinai Hospital in New York.
Dr. Jarou is the immediate Past President of EMRA and an administration fellow at the University of Chicago.
Dr. Hughes is the President-Elect of EMRA and a resident at the University of Cincinnati.