Hrev_master [page 48] [Emergency Care Journal 2022; 18:10870] Emergency Care Journal 2022; volume 18:10870 Dear Editor, As part of the board of CoSMEU – the Italian association of Emergency Medicine (EM) residents – we are looking with great concern at the current situation of the Emergency Departments (ED) and EM in our country,1 and we would like to share our point of view and experience. It is evident that the Italian EDs are collapsing2,3 and CoVID- 19 cannot be considered the only reason. The crisis of our beloved EM has deep roots, and we witness this situation every day. We believe that the overcrowding of EDs cannot be considered the main concern, but rather a symptom of the problem. EDs are open 24/24 and 7/7, being often the only solution for several health conditions, not always urgent and increasingly non-medical. Most of them could be solved differently, but they do not seem to find any other rapid and correct answer in absence of a well-functioning national health system. We are working side by side with EM phy- sicians who have been burned out by work overload for two years now, and often decide to leave a job they have chosen and done with passion because they are exhausted. We cannot judge this choice, but we can understand it and we are deeply sorry because our specialty is certainly more stressful than others, but it gives emotions that make it unique and for us a choice of life. This is the current picture in our country: about 600 EM physicians have cho- sen to leave their careers since January 2022, and EM is no longer attractive for young doctors, since nearly 40% of EM fellowships in 2021-2022 were lost.4 As brilliantly explained by Sorlini,5 a possible solution exists. The UK’s Pre-Hospital Response Unit (PRU), for example, provi- des out-of-hospital medical expertise, seeking to treat and leave patients at home, and they could represent an alternative to the EDs for many patients even in Italy. We could learn from other coun- tries and develop a model of care that provides community EM to patients at home, avoiding stressful situations both for the patients and the emergency clinicians, creating a good collaboration with the patients and their families, and limiting hospitalization only to necessary cases. In our experience, stress is more and more evident in the EDs, and misadventures of verbal or physical violence are unfortunately becoming a common problem nowadays, damaging definitely the doctor-patient relationship of trust, which is the key to the success of our work. Another main issue is the shortage of EM physicians in our health system. To overcome this problem, many Italian regions have started hiring non-specialized physicians to work in the emer- gency room and pre-hospital emergency services, without proper training as desirable. This choice does not lead to an improvement in service quality, but it is a buffer system to quickly solve a pro- blem without considering its long-term consequences. We know well that the EM physician is called upon to provide clinical, dia- gnostic, and therapeutic skills supporting critically ill patients. Decision-making and communication skills, adaptability, attention to detail, and resilience are just some of the qualities that an EM physician must own. This path requires time and the acquisition of skills. Only a specialized traineeship program, of at least 5 years, like the Italian EM one, can allow young doctors to acquire all required skills. To ensure the possibility of good patient outcomes, training must be broad, up-to-date and cover, at least in a general way, all types of pathological conditions, including medical, surgi- cal, trauma, pediatric and gynecological. As stated in the European Curriculum for EM,6 an EM physician needs a deep understanding Correspondence: Isabelle Piazza, Emergency Department, ASST Papa Giovanni XXIII Bergamo, Italy. E-mail: isabellepiazza.isi@gmail.com Key words: Medical education; emergency medicine; residency; spe- cialty training; Italy. Acknowledgements: The authors thank the CoSMEU group and all the Italian emergency medicine residents. Contributions: MC and BB drafted the work contributed to the concep- tion and design of the work; GZ contributed to the conception and the design of the work; IP critically revised the work. All the authors approved the final version to be published. Conflicts of interest: The authors declare no conflict of interest. Availability of data and materials: All data underlying the findings are fully available upon reasonable request to Isabelle Piazza, isabellepiaz- za.isi@gmail.com Ethics approval and consent to participate: N/A Received for publication: 12 September 2022. Revision received: 23 September 2022. Accepted for publication: 23 September 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; 18:10870 doi:10.4081/ecj.2022.10870 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its man- ufacturer is not guaranteed or endorsed by the publisher. Italian Emergency Medicine residents’ perspectives Michela Cascio,1 Bruno Barcella,2 Gianpiero Zaccaria,3 Isabelle Piazza,4 CoSMEU group 1Emergency Department, Policlinico Umberto I, Roma; 2Emergency Department, IRCCS Policlinico San Matteo, Pavia; 3Emergency Department, Azienda Ospedaliero-Universitaria, Careggi; 4Emergency Department, ASST Papa Giovanni XXIII Bergamo, Italy CoSMEU group (Italian Society of Emergency Medicine Residents): Ludovica Ceschi, Adriana D’Ercole, Monica Di Cristoforo, Letizia La Spina, Cecilia Malacarne, Sofia Pons, Giulia Silvestri. Non -co mmerc ial us e o nly of both pre-hospital and hospital emergency medical systems to provide the best care whatever the situation. Italian training pro- grams should improve the standardized and certified training in each university, made up of clinical care, professional activities, training rotations, and simulations to learn all the necessary practi- cal and theoretical skills. In this regard, we believe in the impor- tance of being able to be trained directly by EM specialists, now that their number is increasing. To be able to do so, we think that a specific scientific-disciplinary sector is needed, gradually relea- sing the EM from the current MED/09. Obviously, initial training in Internal Medicine remains crucial, but the EM specialist must also safely master additional skills, such as airway management, sedation and analgesia, trauma, maxi-emergencies, pediatric and obstetric-gynecological emergencies. An area that is unfortunately still underdeveloped in the Italian EM, but no less important, is clinical research. In our experience, the ED is an enormous reservoir of data, from which a large scien- tific production could be obtained. This would allow the Italian emergency residents to gain significant weight in the scientific lite- rature landscape (national and international). We need to become aware that research in EM is possible and we can and must do more as young researchers. The last but not least point concerns our future. Based on our recent survey,4 60% of the EM trainees would like to work both in the ED and in the pre-hospital setting, but only a few hospitals allow this hybrid solution. Certainly, this limit increases the unat- tractively of our specialty. We think that increasing the number of grants and fellowships is important to make our specialty more attractive, but we also strongly believe that it is pivotal to ensure better working condi- tions to avoid burnout and moral injury. Given this background, we are certainly worried about our future. We would be fools to think otherwise! But we have not lost our mojo and indeed, the news of the change of our specialty’s name from Admission and Emergency Medicine and Surgery (MeCAU) to Emergency and Urgency Medicine thrilled us, becau- se it is a sign of rebirth for us and the entire EM. It was only a few days ago that our specialty was recognized by the Italian Ministry of Health on a par with cardiology, gastroenterology, pneumology, internal medicine and geriatrics.7 This measure, which is waiting for final approval, comes 13 years after the birth of our specialty school. In fact, all these specialties have always had equivalences for EM, but there was not vice versa, placing EM at a disadvantage compared to other specialties. However, we believe that this chan- ge is only a small step forward that must be added to a much dee- per reform process that will make the EM truly attractive. Our stre- nuous work must be recognized by an adequate remuneration that considers the impossibility of practicing self-employment. Proper resting time and holidays should be granted, and the reduction of night and holiday shift should get along with seniority grade. We hope that this recognition will be the beginning of a real change, because despite everything, despite the difficulties we experience every day, we still believe that we made the right choi- ce by choosing EM and we continue to learn and work with pas- sion and enthusiasm every day. Using the words of a memorable speech by Steve Jobs in 2005 at the Stanford University graduation ceremony, we want to remain “hungry” and “foolish” hoping that Italian politics will recognize the great value of the Italian national healthcare system and especially of EM (8). References 1. CoSMEU. Available from: https://cosmeu.wordpress.com/ cose-cosmeu/ 2. Coen D, Casagranda I, Cavazza M, et al. Facing the Emergency Department crisis in Italy, Emerg Care J 2021;17:10331. 3. 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. 4. Piazza I, Barcella B, D’Ercole A, et al. Emergency medicine residents in Italy: Data from a national survey. Emerg Care J 2022;18:10439. 5. Sorlini C. Community Emergency Medicine: the right care, at the right time, in the right place. Emerg Care J 2022;18:10595. 6. European Curriculum for Emergency medicine. Available from: https://eusem.org/images/pdf/European_Core_ Curriculum_for_EM_-_Version_1.2_April_2017_final_ver- sion.pdf 7. Repubbblica Italiana, Ministero della Salute. Modifica ai decreti del Ministro della sanità 30 gennaio 1998 e s.m. recante “Tabelle relative alle discipline equipollenti previste dal/a norma/iva regolamentare per l'accesso al secondo livello diri- genziale per il personale del ruolo sanitaria del Servizio sani- taria nazionale" e 31 gennaio 1998 e s.m. recante "Tabella rela- tiva alle specializzazioni affini previste dal/a disciplina concor- suale per il personale dirigenziale del Servizio sanitaria nazio- nale.” Available form: https://www.quotidianosanita.it/allega- ti/allegato1662036999.pdf 8. Jobs S. 2005 Stanford Commencement Address. Available from: https://www.youtube.com/watch?v=UF8uR6Z6KLc Letter [Emergency Care Journal 2022; 18:10870] [page 49] Non -co mmerc ial us e o nly