in september 2008 , the european society of emergency medicine ( eusem ) held their 5th congress of emergency medicine in munich , germany .
cosponsored by the recently founded german society for interdisciplinary emergency medicine [ deutsche gesellschaft interdisziplinre notfallaufnahme ( dgina ) ] , the conference featured sessions ranging from emergency medicine ( em ) education and the  core curriculum  to emergency department design and operations . despite ongoing debate about residency training and the need for specialty board certification for em in germany , it was evident at the meeting that the discussion is expanding from the well - developed prehospital emergency medical services ( ems ) system towards the establishment of integrated , multidisciplinary emergency departments .
this article will review the background and current state of em in germany and discuss some of the current controversies .
.  1 ) has a long tradition of having physicians deliver prehospital emergency care , and traditionally the terms  emergency physician  ( notarzt ) and  emergency medicine  ( notfallmedizin ) have referred exclusively to the prehospital setting .
germany has a two - tiered system with basic life support and advanced life support ( als ) units staffed by emergency medical technicians ( emts ) or paramedics .
each state governs its own ems system , and most have implemented a  rendezvous system ,  where a physician and paramedic travel to the prehospital call in a car , independently of the als units [ 3 , 4 ] .
it is currently a federal mandate that a physician supervise invasive procedures in the field .
nevertheless , critics in germany voice concerns over quality assurance in prehospital medical care , in part because there are no well - established protocols or online medical controls for emts and paramedics . physicians must complete the requirements for  supraspecialty  training in em for prehospital work , as described in detail below . 

1map of germany , population 82,369,522 ( july 2008 est . ) , main language spoken german .
map and information from central intelligence agency world factbook ( https://www.cia.gov/library/publications/the-world-factbook/geos/gm.html ) map of germany , population 82,369,522 ( july 2008 est . ) , main language spoken german .
map and information from central intelligence agency world factbook ( https://www.cia.gov/library/publications/the-world-factbook/geos/gm.html ) hospital - based em in germany differs significantly from the anglo - american model .
( notfallaufnahme , here forth referred to as  emergency rooms  ) within individual hospitals for internal medicine , surgery , trauma , gynecology and obstetrics , pediatrics , and in larger teaching hospitals , there are often additional emergency rooms for ophthalmology and otolaryngology , among others [ 57 ] .
a potential advantage of these single - discipline emergency rooms is the relative ease with which patient care is transferred to the inpatient team .
however , the staff physicians working in these emergency rooms are often still in training ( i.e. , in residency ) , have not necessarily been specifically trained in emergency care , and sometimes work without attending supervision .
in the past decade , many hospitals have created  centralized emergency departments  [ zentrale notaufnahme ( znas ) ] , as discussed below .
these znas are usually staffed by internists , surgeons , anesthesiologists , and other specialists as well as physicians in training .
the demand for hospital - based emergency care is expected to increase in the near future .
germany has a statutory health insurance system , which covers approximately 88% of the population , with private insurance covering almost everyone else . as of 2007
, the german federal statistical office reported that only 0.3% of the total population had no health care coverage .
with relatively easy and affordable access to office - based physicians , as well as 24-h house call service by office - based physicians , emergency rooms and znas had not been a major source of health care in germany .
however , rising health care costs have triggered cost - containment measures , and office - based medicine has become less financially attractive for physicians due to frozen or scaled back reimbursement schedules . there is a trend among german physicians to choose better paying specialties , and it is estimated that there will be a shortage of 15,000 primary care physicians in germany within the next 15  years .
many patients , especially in rural areas and the former east germany , will have very limited or no access to primary care . as has been observed in the usa , poor access to primary care
additional pressure is being imposed on emergency rooms as a result of hospital closures , which are occurring due to decreased reimbursements secondary to a cap of annual spending on health care and the introduction of diagnosis - related groups ( drg ) .
major reasons for increased overhead for hospitals are rising energy prices , increases in staff salaries , and rising cost of care due to the higher morbidity of chronically ill patients .
the german association of emergency physicians [ bundesvereinigung der arbeitsgemeinschaften der notrzte deutschlands ( band ) ] is an umbrella organization for state emergency physician organizations .
band s primary goal has been to improve prehospital care in germany , work towards the establishment of uniform training requirements for physicians nationwide , and to advocate for the interests of emergency physicians . band also cohosted a conference in 2005 where representatives from related political and professional organizations gathered to discuss the future of the zna and hospital - based em .
the other large organization , the german interdisciplinary association of critical care medicine [ deutsche interdisziplinre vereinigung fr intensiv- und notfallmedizin ( divi ) ] , is an association of many medical professional organizations and interest groups that focuses on promoting practice and research in the fields of intensive care medicine and em .
additionally , divi promotes research and quality improvement in prehospital care , transport of critically ill patients , and disaster medicine .
very recently divi has changed its structure and has become a member organization . in addition , several smaller groups that promote inhospital em have been established . in 2004 ,
the bundesarbeitsgemeinschaft zna was founded as an independent  think tank ,  and the aforementioned dgina was established in 2006 .
economic pressure , as well as a changing medical and political environment , has encouraged numerous german hospitals to introduce znas .
the goal is to consolidate services , thereby promoting higher quality care , customer satisfaction , and cost - effectiveness . a majority of znas report to the department of internal medicine or surgery , but a few znas have financial autonomy and report directly to the medical director , ceo , or cfo of the hospital .
an example of a new zna is found in the 955-bed tertiary care hospital , munich - bogenhausen , which combined the medical and surgical emergency rooms into a single , integrated department with the mission to care for all emergency patients as well as patients who present with more routine problems .
acute care  area , which has intensive care capabilities , and additional zones for  intermediate care  and observation .
in the past , critically ill patients would have been admitted directly to the intensive care unit ( icu ) , but in this new zna patients are now stabilized in the acute and intermediate care areas prior to being admitted to the hospital . in some cases , this allows patients to be stabilized and admitted to a non - icu setting , using resources more appropriately and keeping icu beds available for more critically ill patients .
furthermore , this system allows an emergency physician based in the munich - bogenhausen hospital to attend emergencies in the field and then continue caring for the patients when they arrive back in the zna .
supraspecialty ,  and the training requirements for becoming a licensed prehospital em provider include a minimum of 24  months of residency in anesthesia , surgery , internal medicine , or pediatrics . at least 6 of 24 of these months must be spent rotating in anesthesiology , the icu , or an emergency room .
the trainee also must attend an 80-h course covering various aspects of em , as specified by each state medical association .
the final requirement is a praktikum , or internship , under the supervision of a prehospital physician , which includes at least 50 ambulance calls .
however , the complexity of cases and treatment options seen in a zna are considerably broader than in the prehospital environment , and therefore
eusem has defined the practice of em as encompassing prehospital and inhospital triage , resuscitation , initial assessment , and management of undifferentiated urgent and emergency cases .
based on this , a curriculum task force developed an internationally recognized core curriculum for em .
they outlined a 5-year training schedule , including a minimum of 3  years to be spent purely in emergency department - based training , with varying exposure to other specialties , depending on the scope of practice expected in that country .
core competencies ( see table  1 ) , knowledge , and skills were identified which cover clinical aspects of em , as well as other relevant topics , such as the development of prehospital and inhospital emergency medical systems . 

communication , collaboration , and interpersonal skills4 . professionalism and other ethical and legal issues5 .
education and research core competencies in eusem s emergency medicine curriculum dgina has also developed a core curriculum and training requirements for em residency in germany , derived from the eusem document .
the proposed training is 60  months long , with at least 36  months in a zna and 6  months of icu or anesthesiology . up to 18  months of training
can be in surgery or internal medicine , but this is optional and this time can also be done in a zna .
the resident must also complete an 80-h course on em and participate in 50 prehospital emergency calls .
the proposal also enumerates the content and skills that the physician must possess upon completion of training .
eusem has published a policy statement that calls for the recognition of em as a primary medical specialty . currently , however , 16 of 27 european countries , including germany , do not recognize the specialty .
the german medical council [ bundesrztekammer ( bk ) ] is the federal association of all public state medical chambers .
the bk oversees the development of standards for medical specialties , and any changes , including the establishment of new specialties , must be approved by the  parliament of german physicians  ( deutscher rztetag ) . in 2007 , a proposal by moecke and lackner was submitted to the bk outlining suggested responsibilities of the zna and inhospital emergency physicians ( empfehlung der bundesrztekammer zur qualifikation von rztinnen und rzten in zentralen notaufnahmen , personal communication ) .
these include caring for emergency cases , establishing a preliminary diagnosis , determining patient dispositions , treating and releasing stable patients , and the consultation of experts as needed . in 2008 ,
they emphasized the medical and medicolegal risks associated with not having an independent specialty in em .
although znas are gaining acceptance , there is still disagreement about which physicians should be staffing and running these departments .
there is still considerable controversy within the german medical establishment regarding the development of em as an independent medical specialty .
the german society of surgery and the german society of internal medicine published a joint statement in which they argue that the introduction of hospital - based emergency physicians are neither necessary nor cost - effective .
the statement acknowledges that the administration of the zna should be assumed by a single department , but proposes that the directorship should be by the medical specialty which oversees the majority of patients in the zna ( i.e. , internal medicine or surgery ) .
a rotating system of leadership was proposed , alternating between internal medicine and surgery every 23  years . a potential obstacle to board certification in em
it is considered unlikely that the prehospital physician model will be revised or abandoned in the near future . however , with an increasing need for emergency care in germany , prehospital and hospital - based practices will need to be better integrated and more efficient in the future , necessitating that the training programs and career paths for all emergency physicians be more clearly defined .
in germany , inhospital em is changing , with an increasing number of hospitals opening znas .
furthermore , there is an ongoing controversy about the necessary training and qualifications for physicians working in the zna .
 germany has a long tradition of having physicians , often anesthesiologists with additional training in emergency medicine , deliver prehospital emergency care . 
 hospital - based emergency medicine in germany also differs significantly from the anglo - american model , and until recently having separate emergency rooms for different departments was the norm . in the past decade 
 , many hospitals have created  centralized emergency departments  [ zentrale notaufnahme ( znas ) ] . 
 there is ongoing debate about the training and certification of physicians working in the znas and whether germany will adopt a specialty board certification for emergency medicine . 
Introduction
Background of EM in Germany
Professional organizations for EM
The emergence of the centralized emergency department (ZNA)
EM education, training, and certification
Recognition of hospital-based EM as a specialty
Controversies
Conclusions