Emergency medicine (EM) has grown rapidly over the past 50 years, evolving from a specialty defined by its locational identity-a hospital receiving room-to the specialty picked fourth-most-frequently by graduating U.S. medical students and to being the focal point of clinical care and of research on time-sensitive medical conditions. The authors review the forces that led to the growth of EM and those that will shape its future-in particular, cost, quality, and technology. A balancing of cost and quality considerations will likely drive EM education and research endeavors. The future of the field will be determined in part by resolution of the tension between the current inefficient conditions of emergency departments (EDs), which are crowded because of the temporary boarding of admitted patients for whom a bed is not yet ready, and the desired provision of quality care under emergent conditions. That is, patients with stroke, myocardial infarction, sepsis, or severe injuries from trauma require a working diagnosis and interventions that are initiated shortly after presentation, but ED personnel distracted by the demands of caring for boarded patients are unable to deliver optimal ED care. The reduction or elimination of boarding will enhance education and research within EDs and will contribute to an efficient system of high-quality EM services.
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