Complete Story
11/13/2022
History of Military Emergency Medicine
Interview with MAJ (ret) Kenneth Frumkin
GSACEP commissioned this interview with Dr. Kenneth Frumkin as part of its History of Military Emergency Medicine project. Dr. Frumkin currently practices Emergency Medicine as a civilian at the Naval Medical Center in Portsmouth. He served as residency director and chief of Emergency Medicine at Madigan Army Medical Center between 1983 and 1984. Dr. Frumkin brings a unique perspective, having trained some of the first Emergency Medicine residents early in his career, and continuing to train the next generation of military emergency physicians in his current job. During his career, Dr. Frumkin served 11 years on active duty in the Army, and was honorably discharged as a major in 1986.
GSACEP: It seems like you have a strong interest in the importance of training, and more specifically, have helped shape Emergency Medicine residencies to ensure doctors come out of training prepared to do their best within an Emergency Department. Tell us about this interest.
FRUMKIN: When I finished my training, I went to Madigan and became, at some point, responsible for that department. Part of the direction in which we chose to take them was based on my experiences and on the other faculty's experience coming up. The other thing was that emergency rooms had varying reputations. There were a series of scandals—not the right word—but there was a guy who called himself The Phoenix who was an emergency physician who wrote a book called “The Rape of Emergency Medicine”. It was a fictionalized description of how Emergency Departments operated, where schedulers would acquire contracts for money and fill slots in Emergency Departments in various geographic locations with people, accepting money for their services and then pay that doctor considerably less and get quite rich. The guy who started that was literally a gynecologist.
The corporate practice of Emergency Medicine, which is what it came to be known, has had a very bad reputation. There were a couple of well-publicized scandals. There was a relatively famous 60 Minutes episode in the ‘80s…describing a moonlighting guy in Florida employed by one of these groups who had never finished any residency at all, had no known skills, and was involved in the unfortunate death of a child that most people thought could have been prevented by competent care…
GSACEP: How did other specialties respond to Emergency Medicine?
FRUMKIN: Medicine is very much an old boys' club. You earn the right to acceptance as a surgeon by slaving in the trenches as an intern. They impose a pyramidal system on their own trainees, so 20 surgeons enter the internship and five are left at the end. So you have to earn your way into that field.
So here we are a bunch of interlopers trying to do surgical things to some extent without being real surgeons. Or trying to do internal medicine things without being a real internist. In the early stages of Emergency Medicine as a specialty—for quite a long time–one of our tasks was to continually prove ourselves because these guys didn't know what we were. We were trying hard to take care of our patients who then became their patients. They were always critical or wondering about whether or not we had made the correct diagnosis. We had to prove ourselves over and over again.
When you would go into a hospital as a moonlighting resident, you go into a hospital as the first Emergency Medicine physician they've ever seen. They still had this picture of Emergency Medicine doctors as the guys that were in the emergency rooms while they were residents or in private practice, calling them and not knowing what the hell they were talking about, because for a very long time that's who was in the Emergency Departments. It was moonlighting dermatologists and moonlighting whatever and people who had flunked out of other specialties and needed a job as a doctor. That's the reason the specialty was developed and that's the reason it developed criteria and certification examinations and testing and re-testing. It was to correct for the people who'd been practicing Emergency Medicine before it existed as a specialty. They were appropriately suspicious...
Our specialty was becoming more developed. It started out with the guys who got together and didn't want to work nights or didn't want to work unpredictable schedules and formed a group of docs that were just going to work in the emergency room. They were going to give up their private practice and just work in the emergency room. Those guys who ended up forming the American College of Emergency Physicians and then the guys that started the first residency programs...
The second-generation guys like me are people who entered Emergency Medicine residency training and were either taught or influenced by the first-generation guys. So there was a huge deal about “Emergency Department” vs. “Emergency Room”, which has probably finally died out. For the longest time, if someone said the words “emergency room” to you and you were an Emergency Medicine specialist, you felt compelled to correct them. It's an Emergency Department. We don't practice in a room anymore. We're real board-certified, residency-trained guys who are just like you. They don't call it the surgery room. You'd see editorials. I think I even wrote one myself. You will know you've succeeded as a specialty when people stop referring to the emergency room. Interesting enough, I haven't heard that in while. I've stopped worrying about it and I still use the phrase ER and no one goes, “Ooh.” None of the current generation even thinks that's odd.
GSACEP: How were military emergency physicians being trained for combat in the ‘80s?
FRUMKIN: I consider myself very lucky. My entire period on active duty as a doctor, there was no war. We were being trained in the basics of the specialty. There weren't enough Emergency Medicine specialists during my tenure. There was a letter in 1985 from me as Surgeon General's consultant, which said that as of 1 July 1985 we have 69 emergency physicians on active duty, 57 of which were residency trained. Of those, 20 had just graduated, and 12 were from other specialties who qualified to have the military occupational specialty of Emergency Medicine but weren't actually residency-trained and board-certified.
So in 1985, before July when all these new graduates finished their residency training, we had 49 emergency physicians. The number available to provide combat care was pretty limited, and the vast majority of the distributed 49 emergency physicians were located in community hospitals or teaching programs. I finished my residency and went to a teaching program in order to fill the programs with board-certified emergency physicians and get rid of the surgeons and internists, which was a requirement of our residency review committee. Emergency physicians were supposed to be taught by emergency physicians.
Emergency physicians were parceled out to run Emergency Departments at good-sized community hospitals in the states, and to make their Emergency Department better in some fashion. To my knowledge, none of them were training for wartime or had been specifically trained for combat roles. Others were in Fort Bragg, Fort Carson and Europe including Landstuhl. I did make a consultant visit to Europe during one of those years. To my knowledge there weren't any emergency physicians in Korea at that time. Europe and Korea were the two places where we had a significant military presence and a plan for a potential conflict.
One of their tasks in those Emergency Departments was to train their corpsmen in Emergency Medicine techniques and practices. There was a smaller subset of emergency physicians who by virtue of their interest and past experience—and I'm thinking of Sonny Arkangel and guys who followed him—had an interest in warfare. Sonny was a West Point graduate in Special Operations. Those guys who were specifically stationed at Fort Bragg with Delta Force and the Rangers, they trained their medics for the kind of limited combat roles that Delta Force and the Rangers were involved in in the ‘80s.
