Hrev_master [page 26] [Emergency Care Journal 2022; 18:10385] Emergency Care Journal 2022; volume 18:10385 Dear Editors, We have read with great interest the letter by Poggiali et al.1 and your editorial2 published in the issue of December 2021 of Emergency Care Journal. We completely agree with all the obser- vations reported by the authors, and we believe that the point of view of the Italian residents in emergency medicine represented by COSMEU (Coordinamento Specializzandi in Medicina d’Emergenza-Urgenza, the program coordinator of the Italian emergency medicine residents) is crucial to clearly analyse and understand the crisis of the Italian national health system and most of all, of our specialty. We need to take a step back to understand better the current sit- uation. The organization of the Italian Emergency Departments (ED) dramatically changed in the last two years in response to the COVID-19 pandemic. The date 21st February 2020 has marked the beginning of the COVID-19 pandemic and humanitarian crisis in Italy, but most importantly, a strong change for all the Italian emer- gency residents involved in the fight against the spread of SARS- CoV-2.3 We still remember the dramatic scenario of our EDs, and we cannot forget the great effort made by all the emergency physi- cians and nurses to avoid the complete collapse of their hospitals and, as a consequence, of the national health system with catas- trophic consequences.4-7 The EDs have been pushed to change promptly and quickly their organization developing a strategy based on a great resiliency and a bigger effort to fight the pandem- ic, even with limited human resources and spaces. In this contest the role of emergency medicine residents has been crucial as reported by Secco et al.3 Immediately we have been enrolled in the frontline with the unavoidable consequence of a break in our resi- dency program. If we have earned experience points and acquired new skills from this dramatic context, we have also begun to devel- op the thought that our specialty is a “difficult land” unprotected by the Italian government. The major consequence of the Italian outbreak has been the burn-out phenomena, that is pushing emer- gency doctors and residents to abandon the EDs and the emergency medicine specialty. It is clear that the current situation of huge structural shortages of staff and resources in the EDs reflects the poor working condi- tions due to exhausting working hours, inadequate rest periods, and lack of staff compared to the amount of work. It is even clearer that the only way to face the crisis of the emergency medicine is to involve the last resources possible, i.e., young inexperienced doc- tors undergoing specialised medical training. Since the beginning of the COVID-19 pandemic, all the Italian residents in emergency medicine actively participated in tackling the “global disaster” by working side by side with emergency clin- icians, nurses, and paramedics. Hour after hour, day after day, as COVID-19 patients filled the EDs and intensive care units, and critical care beds overflow into hallways, we have worked tireless- ly and rose to every challenge thrown at us in the last two years (2020-2021). Many postgraduate programs, including rotations in other departments, such as radiology, gynaecology, trauma and orthopaedics, coronary care unit, stroke unit, and intensive care unit, have been deleted, with the consequence that many of us have lost their chance to practice and learn in these wards as planned in the residency program. Classes and courses have suffered the same fate since all the residents were called to cover shifts in the COVID-19 EDs. In addition, the spread of the virus among the hospital personnel increased the need of unscheduled shifts and out-of-hours work. For all these reasons, emergency medicine res- idents have been enrolled with precarious contracts promoted by the Italian government to solve more quickly a disastrous situation of instability and mismanagement. We would, nevertheless, like to present the other side of the coin: we have found a source of new opportunities in this dramatic scenario. First of all, we have improved our training experience. We have become confident with lung ultrasound performing hun- dreds of exams in COVID-19 patients,8 and with non-invasive ven- tilation, acquiring considerable skills directly “on the field”. Moreover, the emerging of a new disease has stimulated research Correspondence: Giorgia Borio, Emergency Department, San Raffaele Hospital IRCCS, Milan, Italy. Via Olgettina 60, Milan, Italy. E-mail: borio.giorgia@hsr.it Key words: Emergency medicine; emergency specialty; health crisis; national health system; Italy. Acknowledgements: First and foremost, I would like to express my very great appreciation to Erika Poggiali for giving us the opportunity to bring the point of view of the young emergency medicine doctors to a still ongoing debate involving all the Italian Emergency Care System. Besides, I would like to thank COSMEU for its crucial role in actively promoting and protecting training in emergency medicine in Italy. Conflicts of interest: the author declare no conflict of interest. Availability of data and materials: All data are fully available upon rea- sonable request from Giorgia Borio, borio.giorgia@hsr.it Ethics approval and consent to participate: Not applicable. Informed consent: Not applicable. Received for publication: 28 January 2022. Revision received: 2 February 2022. Accepted for publication: 2 February 2022. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Emergency Care Journal 2022; 18:10385 doi:10.4081/ecj.2022.10385 The crisis of the Italian emergency medicine and specialty: The point of view of COSMEU Giorgia Borio COSMEU (Coordinamento Specializzandi in Medicina d'Emergenza-Urgenza); Emergency Department, San Raffaele Hospital IRCCS, Milan, Italy Non -co mmerc ial us e o nly and emergency medicine residents have played a major role in the design, conduction, and presentation of the results.8-10 For many of us, this has represented the first time to be part of a research team and to have the opportunity to be closely involved in all the pro- cesses behind a research study. In the meantime, what has been happened to our background? We have assisted to a significant growth in the number of emergen- cy medicine trainee positions (119,4% in the last 3 years) reflecting the urge for new specialists in the area. On the other hand, during the last admission test to our specialty, 423 out of 1152 contracts were not awarded. This means that nearly 50% of the scholarships have not been filled, and, in 2020, the dropout rate has been 18%. These numbers are impressive and the reflection of a serious prob- lem that will affect the national health system in the next future for the lack of emergency doctors. We have tried to figure out the rea- son of the failure of our specialty. In a recent survey proposed by COSMEU to the Italian emergency medicine residents, the main reason of the failure of our specialty was indicated in the lack of certainties, protection and recognitions, that push the majority of us to change their career choosing another specialty. Nevertheless, far more than 60% of us would choose again the emergency medicine specialty. Is that surprising? We all think the answer is no, because we are “holistic” specialists who formally embraces all other specialties. In our work we need to be ready to handle any possible acute situation involving any organ or apparatus. In other words, citing Dan Sandberg, “Emergency Medicine is the most interesting 15 minutes of each specialty” and we strongly believe that these words are true. We think a change is needed to solve the crisis of the emergen- cy medicine, starting from the organization of our specialty. It is pivotal to ensure a fair and appropriate preparation to all the emer- gency medicine residents, the appropriate and updated tools to train, the reassurance that there are the necessary protections and working conditions that safeguard their professionalism and a fair evaluation of the fundamental role that those who work in the emergency room play. Looking to our future we are worried, but we must look for- ward. For this reason, we are actively participating in many initia- tives driven by various national emergency associations to quickly work towards a solution with the current Italian health ministry. This letter is the steadfast witness that we want to be actors of the change and not passive observers of the end of the emergency medicine. To paraphrase Mahatma Gandhi, we want to be the change that we wish to see in the emergency medicine. References 1. Poggiali E, Barbieri G, Salvatore V, Salinaro F. The emergency rooms and emergency medicine should not be the answer to the weakness of the Italian National Health System. Emerg Care J 2021;17:10304. 2. Coen D, Casagranda I, Cavazza M, et al. Facing the emergency department crisis in Italy. Emer Care J 2021;17:10331. 3. Secco G, Cappa G, Barcella B, Perlini S. The role of emergen- cy medicine residents during the global SARS-Cov-2 pandem- ic: The Pavia experience. Emerg Care J 2021;17:9747. 4. Comelli I, Scioscioli F, Cervellin G. Impact of the COVID-19 epidemic on census, organization and activity of a large urban Emergency Department. Acta Biomed 2020;91:45-49. 5. Giostra F, Mirarchi MG, Farina G, et al. Impact of COVID-19 pandemic and lockdown on emergency room access in Northern and Central Italy. Emerg Care J 2021;17:9705. 6. Poggiali E, Vercelli A, Cillis MG, et al. Triage decision-mak- ing at the time of COVID-19 infection: the Piacenza strategy. Intern Emerg Med 2020;15:879-882. 7. Barbieri G, Spinelli S, Filippi M, et al. COVID-19 pandemic management at the Emergency Department: the changing sce- nario at the University Hospital of Pisa. Emerg Care J 2020;16:9146. 8. Secco G, Delorenzo M, Zattera C, et al. Lung ultrasound in COVID-19: a useful diagnostic tool. Emerg Care J 2020;16:9017. 9. Poggiali E, Bastoni D, Ferrari M, et al. COVID-19 or not COVID-19, that is the question. The role of screening criteria and point-of-care lung ultrasound in the triage decision-mak- ing process in an Emergency Department during the phase 2 of the COVID-19 Italian epidemic. Emerg Care J 2021;17:9708. 10. Barbieri G, Cipriano A, Carrara S, et al. SARS-CoV-2 manage- ment in Emergency Department: risk stratification and care setting identification proposal based on first pandemic wave in Pisa University Hospital. Emerg Care J 2021;17:9859. Letter [Emergency Care Journal 2022; 18:10385] [page 27] Non -co mmerc ial us e o nly