Observations after 30 years of ACEP S.A.

The Scientific Assembly has changed in three decades, for better AND worse.   

I’m home again for a short period of time. I’m back from the windy city, Carl Sandburg’s “City of the big shoulders,” where the 2008 ACEP Scientific Assembly took place. Having attended these events for the past 30 years, I can’t help but observe and reflect.

Having been in attendance at a council meeting I am reminded of how difficult and problematic and yet necessary democracy is. Certain issues just seem like they won’t go away. I commented to someone sitting next to me that when I die, I will know whether I’ve gone to heaven or hell. If I wake up and they’re debating the fellowship issue, I’m in hell. Fortunately, the council was able to come up with an excellent compromise solution, and let’s hope, for all of our sakes, that this issue has been put to bed. Most of what we do is fiddling while Rome burns. The real issues before us are how we are going to interact with other specialties and with a new administration and congress. For us to spend any more time arguing about letters at the ends of our names only strikes me as ridiculous.

Next, it is amazing to see how the exhibit floor has developed at the ACEP meeting. It is clearly the Broadway of emergency medicine. There is no emergency medicine meeting in the entire world that brings together this many emergency physicians who are the potential buyers of products and the purveyors of those products. It is probably impossible to buy a used car during the ACEP meeting because all of the used car salesmen are selling computer software products. The number of ideas that can come out of a computer is truly amazing. Does any of it actually result in better patient care? That remains to be seen. Does any piece of software move patients through the department faster? I’ve yet to see that proved. Have we really changed the lawsuit rate because of it? All of these questions still remain, and yet people continue to provide electronic alternatives to common sense and common decency.

A third idea, and thank god for it, is that the rage to merge in emergency medicine groups seems to have passed. I remember about ten years ago when the Scientific Assembly could be better described as the “American Association of Acquisition and Mergers in Emergency Medicine.” Someone actually found out that emergency medicine is a relatively low profit business no matter how you cut it. Doctors get paid real money and the amount of money left over is relatively small. It was a pleasure to see very little discussion about mergers, acquisitions and major financial structures at this meeting. The financial discussions were almost all interpersonal . . . and unhappy. Everyone’s 401k has become a 201k. The shift in thinking with regard to retirement and what other avenues one will take to earn a living tended to dominate any larger economic issues. The fact that emergency medicine has been unmasked as a low profit operation has allowed people to move on to other forums of discussion.

The coming together of the best and the brightest in emergency medicine each year directs the policy of how we will interact with the rest of the house of medicine and our largest payer, the federal government. As we await a new congress and a new president, one should never forget the fact that the primary role of ACEP is advocacy for our members. It was very clear that those doing the deep thinking on these issues have used the PAC dollars to gain access to people who will be looking at the health care crisis. The largest issues are not going to be those that are publicly debated, but those that are fought out privately. Those issues which are debated at the RUC committee (where the specialties go to decide what each one is going to be paid by the federal government) will be the new battleground. What is our worth compared to a dermatologist? What is our value compared with a neurologist? As the number of elderly increases and as the complexity of medicine goes forward, how we divide those dollars internally will determine where the best and the brightest of the students will gravitate for their residencies. 

Lastly, having spoken at the national meeting for the past 30 years, it is an absolute pleasure to see the shift in the faculty. I remember a time when half of the faculty came from outside of emergency medicine because we did not have the internal expertise to teach certain subjects. Subjects like cardiology, radiology and neurology were dominated by the specialists in other fields. This is no longer the case. Just to hear the quality of the speakers and the intelligence with which they approach the problems which we see in the emergency department helps us understand that it does matter what your frame of reference is when you are reviewing a problem. Emergency physicians see things raw and uncensored. It is really impossible for a neurosurgeon to speak about head injury evaluation in the ED. Quite frankly, he doesn’t do it! We do. The need to involve “specialists” is the real discussion, and I believe we are now a mature specialty which has a  grasp on its own field of expertise and limitations. It is an absolute reassurance that the profession as a whole is on the right track.


  1. Jim Mensching, DO on

    I’m fascinated to see that this trial went to a jury. I find it incredible that the plaintiff’s expert witness would testify that it is standard of care to make this diagnosis under this clinical setting. Several questions arise – is this physician boarded in EM? What is the expert’s current practice setting – community ED vs teaching hospital/tertiary care center? Was there anything in the testimony that specified if the expert would have his/her testimony reviewed by an outside body such as ACEP or AAEM? This to me strains the boundaries of intellectual honesty.

  2. The fact that this case went to trial is distressing. Equally troubling is the insurance company’s decision to settle, presumably because of uncertainty as to the jury decision. Cases like this serve to mitigate efforts to control costs.

    As Greg Henry suggested in the July 2008 issue of EP Monthly: “What we need is a true change in the paradigm of how malpractice is determined and measured.” He argues for an “intelligent dispute resolution system.” As a new administration attempts to reform the health care system, an integral part of the process should be efforts to change the malpractice system. Without such change, how can we expect to reduce unnecessary services.

  3. After all of the pertinent discussion by Dr. Sullivan and the readers, I find it amazing that the defendant settled for $400,000. Was the physician forced to settle? If so, it would appear that the malpractice carrier did the physician very wrong. And settlements like this only embolden plaintiffs to file weak, long-shot suits like this one – because they pay off anyway.

  4. Thank you Dr Plaster and to all of our boys overseas. I feel guilty at how much I take for granted. After any marginal amount of stress I endure, I can freely saunter down to my bar. Sometimes the biggest decision I face is as to what bottle of wine I must choose from my cellar that would best pair with what I am having for dinner.
    Perhaps other people in the world would be less inclined to killing themselves and other innocent people they have never met if they could enjoy a good drink and to be able to see an unclothed woman every once in a while.

  5. Natalie Painter on

    Entertaining article! It does make me realize how fortunate we are to have all that we do back here “at home.” Thanks for all you do, including keeping our spirits up by writing articles in the way only you can.

  6. Natalie Painter on

    It is unfortunate to realize that cases like this are settled. The illness’ progression couldn’t have been halted even if the physician had ordered an MRI or CTA. Where is the fault for the outcome, and how is this physician responsible for the progression of this patient’s illness?

  7. I like this case for several reasons. It beautifully illustrates how easy it is for fairly serious stuff to get triaged to FT.

    In addition, the x-ray is a classic. It shows not only the mal-alignment at the posterior longitudinal ligament, but the posterior element splaying. As a teaching case, I think it is useful to emphasize looking for this “widening out” of the posterior elements. Sometimes, that will be the only clue to ligamentous instability.


  8. Dr. Scott Whyte on

    Thanks for your service overseas. I had a thought to your “medical dilema” while you are deployed. Although halitosis may be a medical emergency at 2am to some of our patients, which would require STAT mouthwash, we can sense from your writting that the mouthwash was not what the doctor ordered for your illness. If on the other hand you were suspicious that you may have accidentally ingested some ethylene glycol in your “mouthwash” you would not be faulted for starting an ethanol drip (IV or oral) until the ethylene glycol lab levels returned presumably after being sent back to the states for confirmatory testing. To that end I would be happy to send a “medical care package” complete with a 40-80% ethanol IV solution for your use if that would be helpful. All kidding aside I know how much care packages can mean around the holidays so if you have shipping instructions for you and your unit I would like to forward some goodies. Keep up the good work.

  9. J.P.Gregoire MD on

    Thank you Dr. Plaster for your continued good humor and willingness to live your philosophy.
    I agree with Rick G. and his observations! Why do humans feel they have to tell/force others how to live?

  10. I have always aspirated it, if the patient had risk factors for a septic bursea or joint, and it the fluid was grossley normal, then, assumed that it was not septic. Is this wrong? Are you saying that you need a white count and a grm stain on the aspirated fluid to really rule out a spetic process?

  11. Mark Silverberg on

    I agree that you can tell by looking at a sample if the fluid is grossly purulent. You just know it is infected. However, some infections can be “new” or mild and not look terrible but the stain will reveal organisms. Sometimes the fluid may also look terrible but only be crystals and not an infection. You need to send the fluid to the lab and get the number of WBC’s and stain of it to be sure. Even if you make the diagnosis by eye, you still need to get a sample of the fluid to the lab to get sensitivities just in case your treatment fails. In my opinion, it is unsafe to just look at a sample by eye and decide if it is infected or not.

  12. Joseph Soler, MD on

    It is commonly asserted in articles and textbooks that the treatment for carotid artery dissection is heparin followed by coumadin. It would be extremely helpful for your readers to know that the American Stroke Association in their published guidelines, Stroke 2006:37:577-617, state the following:

    “Although it is often stated that treatment with intravenous heparin, followed by 3 to 6 months of therapy with Coumadin, is routine care for patients with a carotid or vertebral dissection (with or without an ischemic stroke), there are no data from prospective randomized studies supporting such an approach.” Page 595

    “A case series of 116 consecutive patients treated with anticoagulation (n=71) and antiplatelet agents (n=23) found no significant differences in outcomes (e.g. TIA, stroke or death) of 8.3 % versus 12.4%, respectively. Meta-analyses comparing rates of death and disability have not found any significant differences between treatment with anticoagulants and antiplatelet agents.” Page 595

    The Guidelines Recommendations state “For patients with ischemic stroke or TIA and extracranial arterial dissection, use of warfarin for 3 to 6 months or use of antiplatelet agent is reasonable. (Class IIa, Level of Evidence B), Page 596. “Aspirin (50 to 325 mg/day), the combination of aspirin and extended-release dipyridamole are all acceptable options for initial therapy.” (Class IIa, Level of Evidence A), Page 595.

    The national organizations supporting/affirming these guidelines are impressive and should dissuade many “experts” from the unfounded repetition of recommendations for which no data exists supporting such an approach.

    “Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Council on Stroke” Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guidelines.” Stroke 2006:37:577-617.

    Thank you for the excellent work that you do in behalf of Emergency Physicians.

  13. David Hoyer, MD FAAEM on

    This article may cause confusion in that it uses the terms “arthritis” and “bursitis” interchangeably despite the fact that they are usually separate clinical entities. The authors’ assumption that data for septic arthritis can be applied to olecranon bursitis in spite of anatomic and prognostic disease differences seems unwarranted.

  14. Doctors Gregoire and Rick G,

    your concerns regarding the killing of innocents and telling/forcing others how to live also brings up the question as to what we are doing in Iraq in the first place. It must be because we love freedom so much, no?

  15. Everytime your kids got sick, parents worried a lot. What if emergency calls and they have nothing in their pockets? Most parents would run after payday loans so they can cover the basic expenses for medical needs of their children. Trips to the emergency room or sudden doctor’s office visits are expensive, and when you have children, you end up going more often. Among the most common afflictions that children suffer, and then their parents along with them, is an incredibly common condition – an ear infection. A way to treat the severe ones is a simple and very common outpatient procedure called a myringotomy. Myringotomy is a procedure in which the eardrum is opened by incision and a tube inserted in order to drain fluid and relieve pressure, like financial pressure can be relieved by payday loans. If you want to read more about it, go to the payday loans blog here.

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