"It’s hard to believe everything that’s transpired over the past two decades.
Emergency medicine at Maryland, reduced to a paltry section within the department of surgery in the mid 1980s after its residency program lost accreditation, is now recognized as one of the nation’s best departments.
Says Ron M. Walls, MD, FRCPC, FACEP, FAAEM, chair of the department of emer- gency medicine at Brigham and Women’s Hospital in Boston, the first professor of emergency medicine at Harvard Medical School, “The department of emergency medicine at Maryland has emerged as one of the leading departments in the country. I think that’s because of its stable leadership, a first-class residency, and a great reputation for outstanding clinical care and training other leaders in our specialty.”
It Started with Just Three
“It was the Wild, Wild West.” That’s how Robert Barish, MD, FACEP, FACP, describes the emergency department at Maryland when he arrived in 1985. In addition to high volumes of patients with medical and surgical emergencies, there was such a high number of victims of violence that “they called us the knife and gun club,” recalls Barish, who was chief of emergency medicine until 1996, and is now vice dean of clinical affairs at the medical school. “We were opening chests—sometimes two or three a night with gunshot and stab wounds—in little trauma bays.” Barish stops, shaking his head in disbelief, but the smile on his face is a fond one.
The impetus behind that change was Barish and his friends and colleagues—Brian J. Browne, MD, FACEP, now acting chair of the department, and associate professor Elizabeth “Betty” Tso, ’79.
Fresh off training, Barish had been offered a position as residency director at Georgetown. He admits to interviewing at Maryland solely for the experience: “I felt people would think I was too young and inexperienced to be chief of emergency medicine. But they offered me the job, and it was an opportunity I couldn’t pass on,” he recalls.
As for Browne, there was only one fellowship in emergency medicine in the country at the time—up at Harvard with Massachusetts General—“and Brian had earned that fellowship,” remembers Barish. “We had kept in contact since training together in medicine at St. Vincent’s Hospital in New York; so I called him after I was hired and offered him the post of clinical director of emergency medicine. I was delighted that he accepted.”
After graduating from Maryland in 1979, Tso had also trained here but had taken a job at Union Memorial Hospital. “I missed Maryland,” she says. “I was comfortable at the school and enjoyed working with the patients,” she adds. “And I was excited to come back and join Bob and
Brian. Plus, it was a golden opportunity to help build a new program from the ground up. There has always been great potential here.”
“We had nothing,” Barish says with a smile. “We were the section, the three of us. They called us the Killer Bs—Bob, Brian, and Betty. There was no faculty; no real program. Imagine walking into that your first day,” Barish says.
Undaunted, the three quickly went to work. “We focused on clinical care and started a program for medical student education right away,” recalls Browne. “We also worked on implementing another residency program and one year later became part of a consortium with Georgetown and George Washington University. It was called the Georgetown/GW/University of Maryland Emergency Medicine Residency.”
Emergency medicine had just become a recognized specialty in 1979; so finding faculty to provide quality care was a challenge. Barish, Browne, and Tso were all board-certified in emergency medicine, but they had more traditional training as well (Barish and Browne were board-certified in medicine, and Tso had done a residency in obstetrics & gynecology before switching to EM). As they were proving themselves as capable clinicians, Barish was also recruiting former colleagues and friends within the small community
of emergency medicine to fill his staff. “We just built it up slowly, and we never lost anybody,” Barish says. “We didn’t lose any faculty, even with a facility that was at the time considered suspect. We had a camaraderie and became very good friends, and we built something out of nothing. It was a real esprit de corps.”
For Tso, it was a riveting experience. “We learned about administration, billing, and getting along with other departments by making some mistakes,” confesses Tso. “Ours was a small mom-and-pop operation. We were coding our own charts in a former janitor’s closet in the ED!” she recalls with a laugh.
On the Move
But by 1990, Maryland was ready to run a residency program on its own. “So we applied as a stand-alone residency with the Shock Trauma Center and the Maryland Institute for Emergency Medical Service Systems as our partners, and we got approved on the first go-around,” says Barish proudly.
The residency was headed by DePriest Whye, MD, JD, who had trained with Barish at Georgetown and is now CEO for the Maryland Medicine Comprehensive Insurance Program. This move toward independence “came with lots of responsibilities,” Browne admits. “But having our own education program is one of the main distinguishing features between a section and a division. And so we were on a roll in the development and advancement of our specialty.”
It took a little more than two decades for the three to realize their ultimate dream of having a department of emergency medicine at Maryland. “It took us 21 years, but we built it from nothing into a complete department,” says Browne. “Achieving the recognition for the medical school in 2006 was extremely important, and it’s also a crowning achievement for one’s career—to be recognized by your peers for this accomplishment.”
All three physicians expressed gratitude for the nurturing support from Morton I. Rapoport, ’60, former CEO of the University of Maryland Medical System, John Kastor, MD, former chair of medicine, and Joseph S. McLaughlin, ’56, former chair of surgery.
Changing with the Times
The “knife and gun club” is no more. These cases are now handled primarily by Shock Trauma. “At one time we had two separate trauma centers, but now they are combined,” Barish explains. “Gunshot wounds, major motor vehicle injuries, and multiple trauma are all routed to Shock Trauma.” Shock Trauma, however, has its own identity. It is located in a separate building with its own mission and multi-disciplinary program, although emergency medicine residents complete a rotation through the center.
Stroke, acute MI, septic shock, pneumonia, internal bleeding, abuse, drugs, alcohol, and psychiatric emergencies—all of this is standard emergency medicine. Yet not all emergency patients have dire medical needs. Many people decide that a two-week wait to see their doctor is too long when a convenient alternative is to sit in the emergency department for a few hours to get a consultation with the most sophisticated imaging. According to Browne, that’s just a sign of the times in which we live.
The emergency department has also become the diagnostic center and silent partner for private doctors who send patients for work-ups after hours. This has led to a shift in the emergency department population. “There’s a popular belief that only the uninsured are accessing emergency rooms,” says Barish. “But it’s people who have insurance, too. They all want answers.”
The convergence of critical care, emergent care, urgent care, convenient care, and after-hours care has led to the overcrowding of emergency departments across America. Because of the efficient way associate professor Dick Kuo, MD, medical director of the emergency department, Browne, and the staff have handled the overcrowding at the University of Maryland Medical Center, the department is now staffing departments at Mercy Medical Center, Bon Secours Hospital, Maryland General Hospital, and the Baltimore Veterans Administration Medical Center. In addition, a statewide network of Washington County Hospital, Memorial Hospital at Easton, Dorchester Hospital, Upper Chesapeake Health System, and Harford Memorial—sees 450,000 patients each year. “They get great emergency departments in exchange for supporting our faculty,” says Browne. “And it’s
given us the chance to expand. It’s worked out extremely well.” In addition, Maryland Expresscare, a critical care and communication transport system, moves 7,500 patients each year from community hospitals to the medical center. The service was developed by Michael Rolnick, MD, and Wade Gaasch, MD.
A Growing Attraction
The broadness of emergency medicine is one of the factors attracting students to the specialty, but Maryland’s leadership also deserves ample credit. With education acting as a top priority, they expanded the scope of teaching as emergency medicine grew from section to division to department. Initially, Tso was in charge. “My special focus has been medical students,” she explains. “I was given the task of creating a student elective in EM for third- and fourth-year students. It has always been an extremely popular elective, as our students get a lot of direct patient contact and responsibility. Patients are our best teachers.”
Kenneth Butler, DO, associate professor and associate residency director, has been responsible for recent upgrades to the emergency medicine component of the medical school curriculum, while Robert Rogers, MD, directs the fourth-year elective. Today their offerings—and emergency medicine in general—continue to flourish, as each year more than 10 percent of Maryland’s graduating class heads into emergency medicine as a career choice.
“We have outstanding clinical physicians and teachers,” Browne adds. “I think that’s extremely important because they’re the reason residents want to come here for their education. The second thing we offer is outstanding opportunity. We’re based in a really great hospital, and our affiliations are outstanding as well.”
Amal Mattu, ’93, residency director for emergency medicine, is an award-winning teacher and nationally recognized for emergency medicine curriculum development. Under his direction, the residency program has blossomed. Maryland is the only institution in the country to have a four-track emergency medicine residency training program. Its primary three-year program accommodates 30 residents. The combined, five-year EM/IM track and six-year, triple boarded EM/IM/critical care track are both co-directed by Michael Winters, MD, and each accept two residents every year. Another two residents are accepted annually for the combined, five-year EM/pediatrics track, co-directed by David Jerrard, MD. Also supporting resident education is a nationally-recognized emergency ultrasound program developed by Brian Euerle, MD.
With such strong talent in the pipeline, Browne is leading another charge—to conquer the field of research with the same success they’ve had with education and clinical practice. “Several members of our faculty have been involved in collaborative research with other departments, and through that synergy we have started getting some noteworthy NIH grants,” he says. “Many of these have been in the area of public health and health surveillance studies, as well as more recent collaborative research with departments such as neurology,” Browne says.
Heading up the department’s research effort are associate professor Jon Mark Hirshon, MD, and associate professor Michael Witting, MD. Hirshon is principal investigator for more than $2.4 million in federal research grants and is principal investigator for an injury prevention training grant in Egypt. It includes traveling with his team to the Middle East to train Iraqi and Egyptian health professionals in emergency preparedness and disaster response.
“We have enormous potential,” concludes Browne. “Maintaining excellence in areas where we’ve already achieved excellence is no less of a priority, though. We have a great program, and we need
to pay attention to it to make certain it stays great.”
Barish is confident it will. “Brian deserves so much credit for bringing this department to where it is today,” he raves. “And I’m excited to see the way it will continue to grow under his leadership.”
Photos by Richard Lippenholz