CODA: Is Emergency Medicine a failed paradigm? Revisited with St Emlyn’s

This week the CODA team have re-released the video and audio from a talk I did with Scott Weingart at SMACC in Dublin. We were tasked with answering the question of whether emergency medicine is a failed paradigm, and it’s a great question.

I think the driver for the debate was a realisation from many leaders thought that the idea that we can do everything for everyone (and everytime) was becoming unsustainable. That was back in 2016 when the world looked very different to the way it does today, but one of the things that we have always tried to do with SMACC and CODA is to look ahead and see what the future holds. Six years down the line seems like a great time to do that. We have previously covered the talk on the blog, but revisiting it as we progress (Ed – stagger) through the pandemic seems right as we face unprecedented pressure on emergency systems in many health economies.

At this point it would be best to watch the video and see how we felt back then. If not then you can read on, but you’ll miss the best bits (i.e. when Scott is talking).

You should also read the CODA blog post here

Since that time so much has changed. In the UK the numbers and type of patients coming to the ED has changed a lot. Not just as a result of COVID, but also because of other structural changes in the way that emergency care is delivered, and more importantly resourced. In the UK, Katherine Henderson our current Royal College of Emergency Medicine president has repeatedly asked us to be clear on what our core business should be. My belief is that it is the emergency assessment and management of the undifferentiated acutely unwell or injured patient, and whilst it’s OK for us to be the safety net for any patient, we can no longer be the safety net for the entire healthcare system.

Similarly, it may well be that we can no longer be clinically excellent in everything that comes through the door. Can we ever be awesome at everything from rashes to REBOA, or will we inevitably see sub specialisation within the speciality as I argued in this post? In my current practice there are now large chunks of non-critical patients who are seen by other services or professions (arguably to a higher standard than I can deliver). As I look to the latter half of my career I need to consider where I am most useful and skilled, and it’s probably not seeing long term minor conditions that cannot find access elsewhere. That’s partly because I don’t enjoy it as much, but also because I’m not that great at it (and others are). I also want to be as good as I can be at the stuff where we can make a difference, and that means keeping up to date with the evidence, skills, knowledge and non-technical skills that support this. For many reasons that’s increasingly difficult in every aspect of what we do.

Back in Dublin I argued against Scott, taking a view that EM was all things to all people in all places. On reflection my position is perhaps closer to his now (and was then). The caveat is that sub-specialisation is probably an ivory-tower luxury and that there will always be the need for true generalists in areas without the ridiculous support and back-up I enjoy in a large teaching hospital/trauma centre..Will we see a differentiation between sub-specialism and generalism even within our incredibly broad speciality? Time, technology, politics and more will no doubt guide (sic) the way forward.

There is no doubt that I am hugely proud of what we achieve in emergency medicine, but as we go forward in a pandemic world and with a new UK curriculum that emphasises the need to acquire and retain critical care skills, it’s it’s once again time to revisit the question.

What do you think?



Further reading.

CODA, “Is EM a failed paradigm?”

Simon Carley, “The BIG questions in EM. Part 1 – Demographics. St.Emlyn’s,” in St.Emlyn’s, June 14, 2016,

Simon Carley, “The BIG questions in EM. Part 2 – Technology. St.Emlyn’s,” in St.Emlyn’s, June 15, 2016,

Simon Carley, “The BIG questions in EM. Part 3 – Politics. St.Emlyn’s,” in St.Emlyn’s, June 16, 2016,

Rick Body, “The Future of Diagnostics #stemlynsLIVE,” in St.Emlyn’s, August 31, 2019,

Simon Carley, “UK Emergency Medicine’s midlife crisis. St.Emlyn’s. #RCEMCPD16,” in St.Emlyn’s, March 7, 2016,

Iain Beardsell, “Securing the Future of the ED workforce? St.Emlyn’s,” in St.Emlyn’s, October 23, 2017,

Dan Horner, “The UK Resuscitationist from #stemlynsLIVE with Dan Horner. St Emlyn’s,” in St.Emlyn’s, September 28, 2019,

Simon Carley, “An uncomfortable truth: Is Emergency Medicine a failed paradigm? St.Emlyn’s,” in St.Emlyn’s, January 23, 2017,

Cite this article as: Simon Carley, "CODA: Is Emergency Medicine a failed paradigm? Revisited with St Emlyn’s," in St.Emlyn's, November 29, 2021,

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