NIH Launches Emergency Care Research Office: Coordinating Center Lauded but Challenges Noted

Abstract

A long-sought goal in the emergency medical community—a point of contact and advocacy within the National Institutes of Health (NIH) for emergency medicine research—was finally achieved in 2012 with the establishment of the Office of Emergency Care Research.1NIH creates Office of Emergency Care ResearchNIH News. 2012http://www.nih.gov/news/health/jul2012/nih-31.htmGoogle ScholarThe office, based within the National Institute of General Medical Sciences, partially satisfies a long-standing desire for NIH to recognize emergency medical research as just as worthy of attention as highly funded specialties, including internal medicine, pathology, and neurology. Although it does not create all the opportunities that advocates had pressed for—the new entity is only an office, lower in the NIH hierarchy than an institute or center—physicians involved in the long lobbying for recognition say it is a significant advance.But they and others caution that the new office will face significant hurdles not only within NIH, where the more powerful institutes and centers retain control over research funding, but also from the greater financial environment, which threatens to reduce federal health agency funding across the board.That does not diminish how welcome they find it.“Until the past decade, there had been little thought of the role of emergency departments or emergency physicians in the investigative efforts funded through the NIH,” said Donald M. Yealy, MD, chair of emergency medicine at the University of Pittsburgh School of Medicine. “This allows us to have a single point of access for all federal research institutes and to show the importance of our work across many different disciplines.”The new office is being steered for the time being by acting director Walter Koroshetz, MD, who is deputy director of NIH's National Institute of Neurological Disorders and Stroke. It is overseen by a steering committee comprising the directors (or their designees) from 5 NIH institutes with an interest in emergency medicine: National Institute of General Medical Sciences, National Institute of Neurological Disorders and Stroke, the National Heart, Lung, and Blood Institute, the National Institute of Nursing Research, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.2OECR Steering CommitteeNational Institute of General Medical Sciences, 2012.http://www.nigms.nih.gov/About/Overview/OECR/OECR_sc.htmGoogle Scholar The office has additional support in the form of the NIH Emergency Care Research Working Group, a 20-member body representing most major divisions of NIH, including the Office of the Director.3NIH Emergency Care Research Working GroupNational Institute of General Medical Sciences, 2012.http://www.nigms.nih.gov/About/Overview/OECR/NIH_emergencygroup.htmGoogle Scholar“NIH is a very big and complex place, and some institutes may not be aware of what other institutes are doing,” said Judith H. Greenberg, PhD, who is acting director of the National Institute of General Medical Sciences and chair of the new office's steering committee. “This office will be serving mainly in a coordinating function: taking an inventory of what is going on now, and what different institutes are supporting, to try to identify gaps, to get institutes to work together, to make sure that what is being funded is really the best that can be funded, and to seek new areas that haven't been supported.”Dr. Koroshetz, who is a distinguished stroke researcher, explained that the ability to coordinate among institutes was a necessary precondition for supporting emergency medicine within NIH. “Think of any research that begins from symptoms—say, chest pain,” he said. “When someone comes into the emergency department with chest pain, you don't know at first what disease they have, and therefore you don't know what institute is relevant. It could be heart, which is National Heart, Lung and Blood Institute; it could be pneumonia, which belongs to the National Institute of Allergy and Infectious Diseases; it could be neuropathy, which would be National Institute of Neurological Disorders and Stroke, or esophageal, which would be National Institute of Diabetes and Digestive and Kidney Diseases. It could even be hysteria, which would be the National Institute of Mental Health.“Symptoms-based research will always cut across multiple institutes,” he added. “But the way the system is put together now, you would have to write a grant that you would sell to a particular one.”Twenty-Year PressThe emergency medical community has been pressing for almost 20 years for the creation of an entity that would focus federal attention on emergency medical research. The effort began with a select conference held in April 1994, sponsored by the Josiah Macy, Jr. Foundation, titled “The Role of Emergency Medicine in the Future of American Health Care.” The Macy conference (the proceedings of which were excerpted in Annals in February 1995) concluded with its 38 participants agreeing to 6 recommendations about access, training, academic standards, classification of emergency departments, and emergency medical research.4Josiah Jr., Macy Foundation. The role of emergency medicine in the future of American medical care.Ann Emerg Med. 1995; 25: 230-233Abstract Full Text Full Text PDF PubMed Scopus (46) Google ScholarAbout research, the participants observed: “The discipline of emergency medicine currently lacks a broadly accepted and defined research agenda. This deficiency impedes its continued development as a clinical field and its fulfillment as an academic medical specialty.” That theme would be sounded repeatedly during the next 2 decades.The Macy Report called for the American College of Emergency Physicians and the Society for Academic Emergency Medicine to convene another conference to develop a research agenda. That gathering, “Research Directions in Emergency Medicine,” took place in January 19955Aghababian R.V. Barsan W.G. Bickell W.H. et al.Research directions in emergency medicine.Am J Emerg Med. 1996; 14: 681-683Abstract Full Text PDF PubMed Scopus (9) Google Scholar; it was followed by a larger conference, “The Future of Emergency Medicine Research,” in March 1997.6Ling L.J. Proceedings of the Future of Emergency Medicine Research Conference, part I: executive summary.Ann Emerg Med. 1998; 31: 155-159Abstract Full Text Full Text PDF PubMed Scopus (7) Google ScholarBoth documented the lack of formal exposure to research offered to emergency medical residents, along with the difficulty of creating research opportunities within a clinically focused training path. They also touched on research efforts being uncoordinated and unfocused. The report of the 1997 conference stressed: “It is vital to maintain research at the top of our priority agenda and to increase visibility and communication with regard to issues important to the effort. We must develop a needs assessment for specific emergency medicine research domains, including basic science, clinical research, health services research, epidemiology, and prevention.”In 2002, the American College of Emergency Physicians' Research Committee assessed progress since the Macy Report and found it slow. In a report published in Annals,7Pollack Jr, C.V. Hollander J.E. O'Neil B.J. et al.Status report: development of emergency medicine research since the Macy Report.Ann Emerg Med. 2003; 42: 66-80Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar representatives of the committee noted that opportunities for research-focused fellowships were still slender, organizing on behalf of research support across specialty organizations had not occurred, and the needs assessment called for in 1997 had not occurred. On the other hand, multicenter research networks were growing in strength, and grant support from NIH and other federal agencies appeared to be increasing.Economic ChallengeThe authors zeroed in on the persistent central difficulty: “The largest challenges to a successful overall emergency medicine–based research agenda remain economic: without adequate funding, there is little hope of sufficient infrastructure, advanced research training, mentorship, release time, laboratory space, statistical support, meeting participation, and testing and validation of new outcome measures.” Backing up that observation, a 2005 review of extramural funding in emergency medical research estimated that only 36% of research in the major emergency medicine journals had received extramural funding compared with 60% in surgical journals and 80% in those covering primary care.8Birkhahn R.H. Van Deusen S.K. Okpara O.I. et al.Funding and publishing trends of original research by emergency medicine investigators over the past decade.Acad Emerg Med. 2006; 13: 95-101Crossref PubMed Scopus (24) Google ScholarThe Institute of Medicine reports on emergency care—formally, “The Future of Emergency Care in the United States Health System”—lifted the conversation about emergency medicine research to a new level.9Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemHospital Based Emergency Care: At the Breaking Point. National Academies Press, Washington, DC2006Google Scholar, 10Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemEmergency Medical Services: At the Crossroads. National Academies Press, Washington, DC2006Google Scholar, 11Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemPediatric Emergency Care: Growing Pains. National Academies Press, Washington, DC2006Google Scholar The lead volume of the 3 interlinked reports, Hospital Based Emergency Care: At the Breaking Point, devoted an entire chapter to the difficulty of defining emergency medical research, the paucity of fellowship opportunities, and the slenderness of federal funding.9Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemHospital Based Emergency Care: At the Breaking Point. National Academies Press, Washington, DC2006Google Scholar Among other data points, the report identified that departments of emergency medicine were receiving 0.05% of NIH training grants, an equivalent of $51.66 per graduating resident, compared with $5,000 per graduating resident for internal medicine.“The emergency care enterprise has accomplished a great deal … through bootstrap funding and poorly supported researchers in a disconnected field,” the authors wrote. “But the field has reached a level of maturity that requires a new approach . . . . The current uncoordinated approach to organizing and funding emergency and trauma care is ineffective.” In their recommendations, they called on the Secretary of the Department of Health and Human Services to authorize a study that would examine, among other initiatives, “… improved research coordination through a dedicated center or institute.”The possibility of a locus of interest for emergency medicine within the government's research apparatus had finally been articulated, but making the possibility a reality was by no means guaranteed. Six months after the Institute of Medicine reports were released, a group of investigators met with NIH director Elias Zerhouni, MD, to explore creating the proposed research center. Preparing to push for building a research infrastructure, they were taken aback by an unexpected question: What's your hypothesis?12Neumar R.W. The Zerhouni challenge: defining the fundamental hypothesis of emergency care research.Ann Emerg Med. 2007; 49: 696-697Abstract Full Text Full Text PDF PubMed Scopus (17) Google ScholarThe resulting soul-searching produced another task force, this time under the auspices of NIH, and another set of conferences, held from December 2008 to June 2009. These sought to define hypotheses and agendas for major subject areas within emergency medicine: neurologic and psychiatric emergencies, medical-surgical emergency, and trauma. Their reports, published in Annals in November 2010, listed knowledge gaps and immediately recognizable research opportunities for each subject, effectively supplying a ready-made list of research priorities that could be launched as soon as the federal establishment was ready.13Cairns C.B. Maier R.V. Adeoye O. et al.NIH roundtable on emergency trauma research.Ann Emerg Med. 2010; 56: 538-550Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 14D'Onofrio G. Jauch E. Jagoda A. et al.NIH roundtable on opportunities to advance research on neurologic and psychiatric emergencies. 2010.Ann Emerg Med. 2010; 56: 551-564Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 15Kaji A.H. Lewis R.J. Beavers-May T. et al.Summary of NIH Medical-Surgical Emergency Research Roundtable held on April 30 to May 1, 2009.Ann Emerg Med. 2010; 56: 522-537Abstract Full Text Full Text PDF PubMed Scopus (34) Google ScholarThe ConundrumAt the same time, the taskforce acknowledged that success in achieving the Institute of Medicine recommendation was not guaranteed. “We are cognizant of the congressional moratorium that blocks the creation of new institutes or centers without eliminating a current one,” Arthur Kellermann, MD, MPH, of Emory University (now the Paul O'Neill Alcoa Chair in Policy Analysis at the RAND Corporation) wrote in an accompanying editorial. “We also know how hard it is to launch, much less sustain, feasible trans-institute initiatives because the dollars required to support them come out of each institute's budget (and must therefore be drawn from other worthy programs). Furthermore, shared efforts require NIH institutes to share power and control.”16Kellermann A.L. Consilience.Ann Emerg Med. 2010; 56: 568-570Abstract Full Text Full Text PDF PubMed Scopus (4) Google ScholarAll of those reports were accompanied by a second editorial, written by Dr. Koroshetz. He said, “NIH is committed to continued support of emergency care research. NIH will work with the emergency care community to increase the quality and numbers of new emergency investigators. NIH-funded emergency research will have an expanding influence on the public health.”17Koroshetz W.J. NIH and research in the emergency setting: progress, promise, and process.Ann Emerg Med. 2010; 56: 565-567Abstract Full Text Full Text PDF PubMed Scopus (6) Google ScholarWith the office now launched and a search for a permanent director set to begin, advocates have moved from celebrating its opening to soberly assessing the remaining roadblocks. There are several.Managing the coordination promised for the new office will be the first, Dr. Kellermann cautioned, and—because the new office has no grant budget of its own—getting the rest of NIH to share its funding will be the second.“The institutes are very autonomous,” he said. “They're very organized around their respective areas of interest, and they each are supported by very dedicated constituencies: patients, specialists, and in some cases, industry. We don't have a large public constituency: Nobody plans on being an emergency patient.”Plus, he added, “discretionary funding is on the chopping block everywhere. If the institutes are getting pressured to reduce spending or curtail resources, they're unlikely to dedicate any revenue streams to work outside their core missions.”The larger version of that concern is the fiscal uncertainty that hangs over the entire government. As this story goes to press, a budget deal has not been achieved between the Administration and Congress, posing a real risk of triggering the billions in automatic cuts that are collectively known as the “fiscal cliff.” Among those cuts is an 8.2% “sequestration” for NIH, amounting to $2.5 billion for fiscal year 2013. Barring a wholesale change of heart among federal negotiators, some cuts to biomedical research are considered likely.18“Fiscal Cliff” threatens to impede biomedical discoveries.Scientific American. 2012http://www.scientificamerican.com/article.cfm?id=fiscal-cliff-threatens-impede-biomedical-discoveriesGoogle ScholarWith the NIH budget already having suffered several cuts in recent years—a change from the budget expansion of a decade ago, when the office was first proposed—the possibility does exist that the new entity will be disadvantaged in the battle for scarce funds. But supporters point to the longevity of NIH's Fogarty International Center, established in 1968, which has built a constituency for crisscrossing research into global health during 35 years of competing for funds. Plus, smaller-scale collaborations on topics related to emergency medicine have already paved the way within NIH, including the Resuscitation Outcomes Consortium and the Neurologic Emergencies Treatment Trials Network.“This office is going to have very modest resources but an opportunity to do a lot of good,” Dr. Kellermann said. “It has a small heart and a thready pulse at the moment, but we have to trust it will strengthen over time.” A long-sought goal in the emergency medical community—a point of contact and advocacy within the National Institutes of Health (NIH) for emergency medicine research—was finally achieved in 2012 with the establishment of the Office of Emergency Care Research.1NIH creates Office of Emergency Care ResearchNIH News. 2012http://www.nih.gov/news/health/jul2012/nih-31.htmGoogle Scholar The office, based within the National Institute of General Medical Sciences, partially satisfies a long-standing desire for NIH to recognize emergency medical research as just as worthy of attention as highly funded specialties, including internal medicine, pathology, and neurology. Although it does not create all the opportunities that advocates had pressed for—the new entity is only an office, lower in the NIH hierarchy than an institute or center—physicians involved in the long lobbying for recognition say it is a significant advance. But they and others caution that the new office will face significant hurdles not only within NIH, where the more powerful institutes and centers retain control over research funding, but also from the greater financial environment, which threatens to reduce federal health agency funding across the board. That does not diminish how welcome they find it. “Until the past decade, there had been little thought of the role of emergency departments or emergency physicians in the investigative efforts funded through the NIH,” said Donald M. Yealy, MD, chair of emergency medicine at the University of Pittsburgh School of Medicine. “This allows us to have a single point of access for all federal research institutes and to show the importance of our work across many different disciplines.” The new office is being steered for the time being by acting director Walter Koroshetz, MD, who is deputy director of NIH's National Institute of Neurological Disorders and Stroke. It is overseen by a steering committee comprising the directors (or their designees) from 5 NIH institutes with an interest in emergency medicine: National Institute of General Medical Sciences, National Institute of Neurological Disorders and Stroke, the National Heart, Lung, and Blood Institute, the National Institute of Nursing Research, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.2OECR Steering CommitteeNational Institute of General Medical Sciences, 2012.http://www.nigms.nih.gov/About/Overview/OECR/OECR_sc.htmGoogle Scholar The office has additional support in the form of the NIH Emergency Care Research Working Group, a 20-member body representing most major divisions of NIH, including the Office of the Director.3NIH Emergency Care Research Working GroupNational Institute of General Medical Sciences, 2012.http://www.nigms.nih.gov/About/Overview/OECR/NIH_emergencygroup.htmGoogle Scholar “NIH is a very big and complex place, and some institutes may not be aware of what other institutes are doing,” said Judith H. Greenberg, PhD, who is acting director of the National Institute of General Medical Sciences and chair of the new office's steering committee. “This office will be serving mainly in a coordinating function: taking an inventory of what is going on now, and what different institutes are supporting, to try to identify gaps, to get institutes to work together, to make sure that what is being funded is really the best that can be funded, and to seek new areas that haven't been supported.” Dr. Koroshetz, who is a distinguished stroke researcher, explained that the ability to coordinate among institutes was a necessary precondition for supporting emergency medicine within NIH. “Think of any research that begins from symptoms—say, chest pain,” he said. “When someone comes into the emergency department with chest pain, you don't know at first what disease they have, and therefore you don't know what institute is relevant. It could be heart, which is National Heart, Lung and Blood Institute; it could be pneumonia, which belongs to the National Institute of Allergy and Infectious Diseases; it could be neuropathy, which would be National Institute of Neurological Disorders and Stroke, or esophageal, which would be National Institute of Diabetes and Digestive and Kidney Diseases. It could even be hysteria, which would be the National Institute of Mental Health. “Symptoms-based research will always cut across multiple institutes,” he added. “But the way the system is put together now, you would have to write a grant that you would sell to a particular one.” Twenty-Year PressThe emergency medical community has been pressing for almost 20 years for the creation of an entity that would focus federal attention on emergency medical research. The effort began with a select conference held in April 1994, sponsored by the Josiah Macy, Jr. Foundation, titled “The Role of Emergency Medicine in the Future of American Health Care.” The Macy conference (the proceedings of which were excerpted in Annals in February 1995) concluded with its 38 participants agreeing to 6 recommendations about access, training, academic standards, classification of emergency departments, and emergency medical research.4Josiah Jr., Macy Foundation. The role of emergency medicine in the future of American medical care.Ann Emerg Med. 1995; 25: 230-233Abstract Full Text Full Text PDF PubMed Scopus (46) Google ScholarAbout research, the participants observed: “The discipline of emergency medicine currently lacks a broadly accepted and defined research agenda. This deficiency impedes its continued development as a clinical field and its fulfillment as an academic medical specialty.” That theme would be sounded repeatedly during the next 2 decades.The Macy Report called for the American College of Emergency Physicians and the Society for Academic Emergency Medicine to convene another conference to develop a research agenda. That gathering, “Research Directions in Emergency Medicine,” took place in January 19955Aghababian R.V. Barsan W.G. Bickell W.H. et al.Research directions in emergency medicine.Am J Emerg Med. 1996; 14: 681-683Abstract Full Text PDF PubMed Scopus (9) Google Scholar; it was followed by a larger conference, “The Future of Emergency Medicine Research,” in March 1997.6Ling L.J. Proceedings of the Future of Emergency Medicine Research Conference, part I: executive summary.Ann Emerg Med. 1998; 31: 155-159Abstract Full Text Full Text PDF PubMed Scopus (7) Google ScholarBoth documented the lack of formal exposure to research offered to emergency medical residents, along with the difficulty of creating research opportunities within a clinically focused training path. They also touched on research efforts being uncoordinated and unfocused. The report of the 1997 conference stressed: “It is vital to maintain research at the top of our priority agenda and to increase visibility and communication with regard to issues important to the effort. We must develop a needs assessment for specific emergency medicine research domains, including basic science, clinical research, health services research, epidemiology, and prevention.”In 2002, the American College of Emergency Physicians' Research Committee assessed progress since the Macy Report and found it slow. In a report published in Annals,7Pollack Jr, C.V. Hollander J.E. O'Neil B.J. et al.Status report: development of emergency medicine research since the Macy Report.Ann Emerg Med. 2003; 42: 66-80Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar representatives of the committee noted that opportunities for research-focused fellowships were still slender, organizing on behalf of research support across specialty organizations had not occurred, and the needs assessment called for in 1997 had not occurred. On the other hand, multicenter research networks were growing in strength, and grant support from NIH and other federal agencies appeared to be increasing. The emergency medical community has been pressing for almost 20 years for the creation of an entity that would focus federal attention on emergency medical research. The effort began with a select conference held in April 1994, sponsored by the Josiah Macy, Jr. Foundation, titled “The Role of Emergency Medicine in the Future of American Health Care.” The Macy conference (the proceedings of which were excerpted in Annals in February 1995) concluded with its 38 participants agreeing to 6 recommendations about access, training, academic standards, classification of emergency departments, and emergency medical research.4Josiah Jr., Macy Foundation. The role of emergency medicine in the future of American medical care.Ann Emerg Med. 1995; 25: 230-233Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar About research, the participants observed: “The discipline of emergency medicine currently lacks a broadly accepted and defined research agenda. This deficiency impedes its continued development as a clinical field and its fulfillment as an academic medical specialty.” That theme would be sounded repeatedly during the next 2 decades. The Macy Report called for the American College of Emergency Physicians and the Society for Academic Emergency Medicine to convene another conference to develop a research agenda. That gathering, “Research Directions in Emergency Medicine,” took place in January 19955Aghababian R.V. Barsan W.G. Bickell W.H. et al.Research directions in emergency medicine.Am J Emerg Med. 1996; 14: 681-683Abstract Full Text PDF PubMed Scopus (9) Google Scholar; it was followed by a larger conference, “The Future of Emergency Medicine Research,” in March 1997.6Ling L.J. Proceedings of the Future of Emergency Medicine Research Conference, part I: executive summary.Ann Emerg Med. 1998; 31: 155-159Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Both documented the lack of formal exposure to research offered to emergency medical residents, along with the difficulty of creating research opportunities within a clinically focused training path. They also touched on research efforts being uncoordinated and unfocused. The report of the 1997 conference stressed: “It is vital to maintain research at the top of our priority agenda and to increase visibility and communication with regard to issues important to the effort. We must develop a needs assessment for specific emergency medicine research domains, including basic science, clinical research, health services research, epidemiology, and prevention.” In 2002, the American College of Emergency Physicians' Research Committee assessed progress since the Macy Report and found it slow. In a report published in Annals,7Pollack Jr, C.V. Hollander J.E. O'Neil B.J. et al.Status report: development of emergency medicine research since the Macy Report.Ann Emerg Med. 2003; 42: 66-80Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar representatives of the committee noted that opportunities for research-focused fellowships were still slender, organizing on behalf of research support across specialty organizations had not occurred, and the needs assessment called for in 1997 had not occurred. On the other hand, multicenter research networks were growing in strength, and grant support from NIH and other federal agencies appeared to be increasing. Economic ChallengeThe authors zeroed in on the persistent central difficulty: “The largest challenges to a successful overall emergency medicine–based research agenda remain economic: without adequate funding, there is little hope of sufficient infrastructure, advanced research training, mentorship, release time, laboratory space, statistical support, meeting participation, and testing and validation of new outcome measures.” Backing up that observation, a 2005 review of extramural funding in emergency medical research estimated that only 36% of research in the major emergency medicine journals had received extramural funding compared with 60% in surgical journals and 80% in those covering primary care.8Birkhahn R.H. Van Deusen S.K. Okpara O.I. et al.Funding and publishing trends of original research by emergency medicine investigators over the past decade.Acad Emerg Med. 2006; 13: 95-101Crossref PubMed Scopus (24) Google ScholarThe Institute of Medicine reports on emergency care—formally, “The Future of Emergency Care in the United States Health System”—lifted the conversation about emergency medicine research to a new level.9Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemHospital Based Emergency Care: At the Breaking Point. National Academies Press, Washington, DC2006Google Scholar, 10Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemEmergency Medical Services: At the Crossroads. National Academies Press, Washington, DC2006Google Scholar, 11Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemPediatric Emergency Care: Growing Pains. National Academies Press, Washington, DC2006Google Scholar The lead volume of the 3 interlinked reports, Hospital Based Emergency Care: At the Breaking Point, devoted an entire chapter to the difficulty of defining emergency medical research, the paucity of fellowship opportunities, and the slenderness of federal funding.9Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemHospital Based Emergency Care: At the Breaking Point. National Academies Press, Washington, DC2006Google Scholar Among other data points, the report identified that departments of emergency medicine were receiving 0.05% of NIH training grants, an equivalent of $51.66 per graduating resident, compared with $5,000 per graduating resident for internal medicine.“The emergency care enterprise has accomplished a great deal … through bootstrap funding and poorly supported researchers in a disconnected field,” the authors wrote. “But the field has reached a level of maturity that requires a new approach . . . . The current uncoordinated approach to organizing and funding emergency and trauma care is ineffective.” In their recommendations, they called on the Secretary of the Department of Health and Human Services to authorize a study that would examine, among other initiatives, “… improved research coordination through a dedicated center or institute.”The possibility of a locus of interest for emergency medicine within the government's research apparatus had finally been articulated, but making the possibility a reality was by no means guaranteed. Six months after the Institute of Medicine reports were released, a group of investigators met with NIH director Elias Zerhouni, MD, to explore creating the proposed research center. Preparing to push for building a research infrastructure, they were taken aback by an unexpected question: What's your hypothesis?12Neumar R.W. The Zerhouni challenge: defining the fundamental hypothesis of emergency care research.Ann Emerg Med. 2007; 49: 696-697Abstract Full Text Full Text PDF PubMed Scopus (17) Google ScholarThe resulting soul-searching produced another task force, this time under the auspices of NIH, and another set of conferences, held from December 2008 to June 2009. These sought to define hypotheses and agendas for major subject areas within emergency medicine: neurologic and psychiatric emergencies, medical-surgical emergency, and trauma. Their reports, published in Annals in November 2010, listed knowledge gaps and immediately recognizable research opportunities for each subject, effectively supplying a ready-made list of research priorities that could be launched as soon as the federal establishment was ready.13Cairns C.B. Maier R.V. Adeoye O. et al.NIH roundtable on emergency trauma research.Ann Emerg Med. 2010; 56: 538-550Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 14D'Onofrio G. Jauch E. Jagoda A. et al.NIH roundtable on opportunities to advance research on neurologic and psychiatric emergencies. 2010.Ann Emerg Med. 2010; 56: 551-564Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 15Kaji A.H. Lewis R.J. Beavers-May T. et al.Summary of NIH Medical-Surgical Emergency Research Roundtable held on April 30 to May 1, 2009.Ann Emerg Med. 2010; 56: 522-537Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar The authors zeroed in on the persistent central difficulty: “The largest challenges to a successful overall emergency medicine–based research agenda remain economic: without adequate funding, there is little hope of sufficient infrastructure, advanced research training, mentorship, release time, laboratory space, statistical support, meeting participation, and testing and validation of new outcome measures.” Backing up that observation, a 2005 review of extramural funding in emergency medical research estimated that only 36% of research in the major emergency medicine journals had received extramural funding compared with 60% in surgical journals and 80% in those covering primary care.8Birkhahn R.H. Van Deusen S.K. Okpara O.I. et al.Funding and publishing trends of original research by emergency medicine investigators over the past decade.Acad Emerg Med. 2006; 13: 95-101Crossref PubMed Scopus (24) Google Scholar The Institute of Medicine reports on emergency care—formally, “The Future of Emergency Care in the United States Health System”—lifted the conversation about emergency medicine research to a new level.9Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemHospital Based Emergency Care: At the Breaking Point. National Academies Press, Washington, DC2006Google Scholar, 10Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemEmergency Medical Services: At the Crossroads. National Academies Press, Washington, DC2006Google Scholar, 11Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemPediatric Emergency Care: Growing Pains. National Academies Press, Washington, DC2006Google Scholar The lead volume of the 3 interlinked reports, Hospital Based Emergency Care: At the Breaking Point, devoted an entire chapter to the difficulty of defining emergency medical research, the paucity of fellowship opportunities, and the slenderness of federal funding.9Institute of Medicine Committee on the Future of Emergency Care in the US Health SystemHospital Based Emergency Care: At the Breaking Point. National Academies Press, Washington, DC2006Google Scholar Among other data points, the report identified that departments of emergency medicine were receiving 0.05% of NIH training grants, an equivalent of $51.66 per graduating resident, compared with $5,000 per graduating resident for internal medicine. “The emergency care enterprise has accomplished a great deal … through bootstrap funding and poorly supported researchers in a disconnected field,” the authors wrote. “But the field has reached a level of maturity that requires a new approach . . . . The current uncoordinated approach to organizing and funding emergency and trauma care is ineffective.” In their recommendations, they called on the Secretary of the Department of Health and Human Services to authorize a study that would examine, among other initiatives, “… improved research coordination through a dedicated center or institute.” The possibility of a locus of interest for emergency medicine within the government's research apparatus had finally been articulated, but making the possibility a reality was by no means guaranteed. Six months after the Institute of Medicine reports were released, a group of investigators met with NIH director Elias Zerhouni, MD, to explore creating the proposed research center. Preparing to push for building a research infrastructure, they were taken aback by an unexpected question: What's your hypothesis?12Neumar R.W. The Zerhouni challenge: defining the fundamental hypothesis of emergency care research.Ann Emerg Med. 2007; 49: 696-697Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar The resulting soul-searching produced another task force, this time under the auspices of NIH, and another set of conferences, held from December 2008 to June 2009. These sought to define hypotheses and agendas for major subject areas within emergency medicine: neurologic and psychiatric emergencies, medical-surgical emergency, and trauma. Their reports, published in Annals in November 2010, listed knowledge gaps and immediately recognizable research opportunities for each subject, effectively supplying a ready-made list of research priorities that could be launched as soon as the federal establishment was ready.13Cairns C.B. Maier R.V. Adeoye O. et al.NIH roundtable on emergency trauma research.Ann Emerg Med. 2010; 56: 538-550Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 14D'Onofrio G. Jauch E. Jagoda A. et al.NIH roundtable on opportunities to advance research on neurologic and psychiatric emergencies. 2010.Ann Emerg Med. 2010; 56: 551-564Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 15Kaji A.H. Lewis R.J. Beavers-May T. et al.Summary of NIH Medical-Surgical Emergency Research Roundtable held on April 30 to May 1, 2009.Ann Emerg Med. 2010; 56: 522-537Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar The ConundrumAt the same time, the taskforce acknowledged that success in achieving the Institute of Medicine recommendation was not guaranteed. “We are cognizant of the congressional moratorium that blocks the creation of new institutes or centers without eliminating a current one,” Arthur Kellermann, MD, MPH, of Emory University (now the Paul O'Neill Alcoa Chair in Policy Analysis at the RAND Corporation) wrote in an accompanying editorial. “We also know how hard it is to launch, much less sustain, feasible trans-institute initiatives because the dollars required to support them come out of each institute's budget (and must therefore be drawn from other worthy programs). Furthermore, shared efforts require NIH institutes to share power and control.”16Kellermann A.L. Consilience.Ann Emerg Med. 2010; 56: 568-570Abstract Full Text Full Text PDF PubMed Scopus (4) Google ScholarAll of those reports were accompanied by a second editorial, written by Dr. Koroshetz. He said, “NIH is committed to continued support of emergency care research. NIH will work with the emergency care community to increase the quality and numbers of new emergency investigators. NIH-funded emergency research will have an expanding influence on the public health.”17Koroshetz W.J. NIH and research in the emergency setting: progress, promise, and process.Ann Emerg Med. 2010; 56: 565-567Abstract Full Text Full Text PDF PubMed Scopus (6) Google ScholarWith the office now launched and a search for a permanent director set to begin, advocates have moved from celebrating its opening to soberly assessing the remaining roadblocks. There are several.Managing the coordination promised for the new office will be the first, Dr. Kellermann cautioned, and—because the new office has no grant budget of its own—getting the rest of NIH to share its funding will be the second.“The institutes are very autonomous,” he said. “They're very organized around their respective areas of interest, and they each are supported by very dedicated constituencies: patients, specialists, and in some cases, industry. We don't have a large public constituency: Nobody plans on being an emergency patient.”Plus, he added, “discretionary funding is on the chopping block everywhere. If the institutes are getting pressured to reduce spending or curtail resources, they're unlikely to dedicate any revenue streams to work outside their core missions.”The larger version of that concern is the fiscal uncertainty that hangs over the entire government. As this story goes to press, a budget deal has not been achieved between the Administration and Congress, posing a real risk of triggering the billions in automatic cuts that are collectively known as the “fiscal cliff.” Among those cuts is an 8.2% “sequestration” for NIH, amounting to $2.5 billion for fiscal year 2013. Barring a wholesale change of heart among federal negotiators, some cuts to biomedical research are considered likely.18“Fiscal Cliff” threatens to impede biomedical discoveries.Scientific American. 2012http://www.scientificamerican.com/article.cfm?id=fiscal-cliff-threatens-impede-biomedical-discoveriesGoogle ScholarWith the NIH budget already having suffered several cuts in recent years—a change from the budget expansion of a decade ago, when the office was first proposed—the possibility does exist that the new entity will be disadvantaged in the battle for scarce funds. But supporters point to the longevity of NIH's Fogarty International Center, established in 1968, which has built a constituency for crisscrossing research into global health during 35 years of competing for funds. Plus, smaller-scale collaborations on topics related to emergency medicine have already paved the way within NIH, including the Resuscitation Outcomes Consortium and the Neurologic Emergencies Treatment Trials Network.“This office is going to have very modest resources but an opportunity to do a lot of good,” Dr. Kellermann said. “It has a small heart and a thready pulse at the moment, but we have to trust it will strengthen over time.” At the same time, the taskforce acknowledged that success in achieving the Institute of Medicine recommendation was not guaranteed. “We are cognizant of the congressional moratorium that blocks the creation of new institutes or centers without eliminating a current one,” Arthur Kellermann, MD, MPH, of Emory University (now the Paul O'Neill Alcoa Chair in Policy Analysis at the RAND Corporation) wrote in an accompanying editorial. “We also know how hard it is to launch, much less sustain, feasible trans-institute initiatives because the dollars required to support them come out of each institute's budget (and must therefore be drawn from other worthy programs). Furthermore, shared efforts require NIH institutes to share power and control.”16Kellermann A.L. Consilience.Ann Emerg Med. 2010; 56: 568-570Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar All of those reports were accompanied by a second editorial, written by Dr. Koroshetz. He said, “NIH is committed to continued support of emergency care research. NIH will work with the emergency care community to increase the quality and numbers of new emergency investigators. NIH-funded emergency research will have an expanding influence on the public health.”17Koroshetz W.J. NIH and research in the emergency setting: progress, promise, and process.Ann Emerg Med. 2010; 56: 565-567Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar With the office now launched and a search for a permanent director set to begin, advocates have moved from celebrating its opening to soberly assessing the remaining roadblocks. There are several. Managing the coordination promised for the new office will be the first, Dr. Kellermann cautioned, and—because the new office has no grant budget of its own—getting the rest of NIH to share its funding will be the second. “The institutes are very autonomous,” he said. “They're very organized around their respective areas of interest, and they each are supported by very dedicated constituencies: patients, specialists, and in some cases, industry. We don't have a large public constituency: Nobody plans on being an emergency patient.” Plus, he added, “discretionary funding is on the chopping block everywhere. If the institutes are getting pressured to reduce spending or curtail resources, they're unlikely to dedicate any revenue streams to work outside their core missions.” The larger version of that concern is the fiscal uncertainty that hangs over the entire government. As this story goes to press, a budget deal has not been achieved between the Administration and Congress, posing a real risk of triggering the billions in automatic cuts that are collectively known as the “fiscal cliff.” Among those cuts is an 8.2% “sequestration” for NIH, amounting to $2.5 billion for fiscal year 2013. Barring a wholesale change of heart among federal negotiators, some cuts to biomedical research are considered likely.18“Fiscal Cliff” threatens to impede biomedical discoveries.Scientific American. 2012http://www.scientificamerican.com/article.cfm?id=fiscal-cliff-threatens-impede-biomedical-discoveriesGoogle Scholar With the NIH budget already having suffered several cuts in recent years—a change from the budget expansion of a decade ago, when the office was first proposed—the possibility does exist that the new entity will be disadvantaged in the battle for scarce funds. But supporters point to the longevity of NIH's Fogarty International Center, established in 1968, which has built a constituency for crisscrossing research into global health during 35 years of competing for funds. Plus, smaller-scale collaborations on topics related to emergency medicine have already paved the way within NIH, including the Resuscitation Outcomes Consortium and the Neurologic Emergencies Treatment Trials Network. “This office is going to have very modest resources but an opportunity to do a lot of good,” Dr. Kellermann said. “It has a small heart and a thready pulse at the moment, but we have to trust it will strengthen over time.”