An ACEP16 Special Edition

“The greatest challenge to the concept of democracy is spending five minutes talking to the average voter.” -Winston Churchill

Every year I attempt to give some perspective to what has transpired at the Annual Council Meeting of the American College of Emergency Physicians. I have no idea what will happen this week in Las Vegas, but allow me to give you some thoughts on the democratic process with our Council Meeting as the exemplar reference.

Before I get to the actual resolutions, let me give you some ground rules. First, ACEP is in essence a professional trade organization. I know, because I was its president 20 years ago. I was president during the Clinton Administration and I was the one who had to tell Hillary that we were not signing onto “her” health plan. It was awful. You never heard such name calling, threatening, cajoling and pontificating in your life. Let’s just say I’m not the precise personality to do this to. It didn’t go well. But it taught me lessons about power, politics and the fact that people will “little note nor long remember” what we mere mortals do today.

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A healthy skepticism and distrust of all organizations, both governmental and voluntary, is wise. A perverse disquiet has fallen over the land and is transforming our society and politics all the way from the White House up to the ACEP Council and board of directors. We are a reflection of the collective vicissitudes abroad in the land. The new insecurity of the new rules of society are everywhere. Gone are the days of secure positions and predictable pecking orders. The role of the doctor, nurse, and other technicians are being challenged by the new levels of providers and the universal [Shall I say international?] threat to our halcyon days and to our cherished spirits and expectations.

Let’s review the yearly conflict which exists between our Councilors, the people we send to give direction to our board of directors, and the rest of the membership who are home working for a living. People who pay dues to the organization are interested in their careers and their lives. They want to be able to live predictable, decent and honorable existences. They send us to the Council Meeting to secure their benefits. We represent them because no one else does. If you think for one second you have been sent there as a Councilor to save the world, you’re wrong, period. Emergency doctors are keenly interested in their remuneration, liability, safety, security and status within the medical community. Any time we touch on one of these hot button issues, we are doing the work we were sent there to do. Like the Cosa Nostra, protection is our first and most important business.

Some reflections on democracy even at the professional organizational level are needed. Jonathan Sachs warns us of the perennial temptations of the market. We must be aware of who is asking for what and why. On first hearing the resolution, the first thought is: What itch is it that needs to be scratched? And what do these folks really want, saving a chance to be rhetorical and overblown?

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Jefferson, one of my heroes, had heroes himself. He possessed small portraits of each, which he kept on his desk to look at every day he wrote. Newton was there to remind him of the natural laws, which we as mortals have no power to change – don’t even bother. Sir Francis Bacon, who although a lawyer, understood that the discovery process toward truth is ugly, untidy but relentless. And lastly, John Locke, the shooting star of the Scottish Enlightenment, who understood that here on earth God’s work must surely be our own and thus justified our right for self-government. I think we should keep these gentlemen in mind as we weigh the resolutions which are to come before us.

Now the resolutions, remembering I have only read the original submissions. We start out with commendations. I know these people. We do not do enough for those who have given their time and effort on our behalf. Virtue may be its own reward but I want to thank them for their service. To Ken DeHart, a departed colleague and friend, I say: Sit tibi terra levis. I gave my first Mill’s lecture in his honor. If there is a better human being, bring him forth for examination because I do not believe one exists.

Resolution Five deserves comment. This would give a young physician a position on the board of directors. I understand I am tilting at windmills here but I refuse to drink the clone juice. I’m against the principle. I think the best people who we believe can handle the job and advocate for our positions should win. No special anything. Do you next want to have a minority seat? Do you want an elderly seat? Let everyone who wants to run run. Special seats are the surest sign of mediocrity. It says without “special help” one cannot get there on their own. Let the membership decide who they are willing to follow.

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Resolution Six has some potential meat. This resolution is vague but it hints at the problem we all must face, i.e. getting older. The resolution asks the board to study specific issues related to older physicians and recognize that emergency medicine is not dermatology. What are we going to do at age 65 with four midnight shifts in a row coming up? This is a core issue. In 20 years we’ll each be 20 years older or dead. There are no alternatives.

Many years ago I suggested – and I talked to the board and to the Council – that we as emergency medicine take over the urgent care movement, both inside and outside the emergency departments of hospitals of these United States. The academics went nuts. How could I suggest such an impure and unholy thing? Well, you see what’s happened. Funny how people’s views now change as they get older. This is a real issue for which we are now paying for our mistakes.

Resolution Seven is again vague, without direction but carries a sense or a feeling that does need to be addressed: diversity. The board is asked to develop strategies to address the fact that composition of the board, our leadership does not represent the make-up of the American public at large. In a technical field, I have no idea how you do this. The pipeline is long. The cursis honorum is hard. At the University of Michigan, the vast majority of physics graduate students are from the Asian or Asian subcontinent backgrounds. This certainly does not represent the country at large. But does this represent anything sinister? Perhaps the National Football League needs a program to encourage diversity in its defensive backs? This is a harder question and it isn’t going to be answered quickly and if you have good ideas, all of us would like to hear them.

Resolution Eight raises an issue with both consternation and concern. The Texas Chapter has asked for the College to oppose mandatory required high-stakes secure examinations for maintenance of certification. Good issue but we are asking the wrong question. What should we as a profession be doing to keep our members reasonably current in the science of emergency medicine? You all realize that we do not all agree on what is or isn’t the current standard of care. What was gospel five years ago is now garbage. What is more difficult to deal with is that things that were in vogue 15 years ago went out of style only to come back again and be the latest thing. Ties get wide. Ties get narrow. Pants get cuffs. Now cuffs are gone. There is not an end in this vicious cycle.

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The real issue is the time, effort and cost of keeping up. Do you really need to redo ACLS every five years, since most of it doesn’t work? Who says those 200 articles you’re supposed to read each year are any good? The American College of Internal Medicine told the ACGME to stick it in their nose. Why shouldn’t we do the same? We need to reframe the questions. But this issue will not go away. Re-credentialing could become not only expensive but endless.

Let’s get down to the money. Resolution Nine asks for ACEP to endorse standards [minimum, of course] for any place that calls itself a free-standing emergency center. People don’t like the fact that insured patients are going elsewhere. The resolution plays games with wording like “accreditation” versus “licensing” but it is just that: a game. It’s who is going to get a piece of the insurance pie. If you are looking for internecine warfare, this is it. This has everything: blood, gore, rich versus poor, money, location and degradation. You got to love it. Stay tuned because the world is changing. How’s our organization going to view such places?

Whenever there are more than three resolutions on an issue, somebody’s unhappy. This goes along with Resolution Eleven, asking for CMS recognition of independently licensed free-standing emergency centers. The basic issue is: Who gets the nonpaying, difficult case? Everybody wants the 16-year-old insured kid with a Colles fracture. Who wants or should have to take the ambulance patient who is intoxicated, suffering from a small head wound and smells bad?

Apple pie, motherhood and the American way is the only way I can describe Resolution Thirteen, which deals with crowding. I would use the term “overcrowding” but Rick Bukata taught us years ago that this was laying it on a little thick. How can you be against ACEP working with DHS? Define some way to reduce emergency department crowding. This is again a lifestyle and job satisfaction issue for every practicing member of the organization. It’s the kind of thing which depresses the membership and makes them wish they had gone into radiation oncology. Do I have much hope that there will be different results from the last time we passed a resolution? Nah, probably not. But this is and should be a perpetual item. Peter Viccellio needs our support. Let’s give it to him.

Its companion, Resolution Fourteen, narrows the field down to clinical, quality data related to the management and boarding of psych patients in the emergency department. Talk about a physician lifestyle issue. It’s a financial issue, it’s a status issue, it’s a liability issue. This has everything our membership wants for us to take action on. I know, let’s send them all to free-standing emergency departments.

Time – by that I mean column length – does not allow me to comment on many more of these issues; except to say anything that has to do with network payments, collection of deductibles by insurance companies or the bundling of payments is the business of the organization, which most emergency doctors pay dues to. This is where we need to be because no individual doctor, small group or even mega group can fight these fights by themselves.

There are many more worthwhile resolutions. But I want to comment on only one more and basically on the philosophy behind Resolution Eighteen, which is opposition to CMS mandating treatment expectations on “our patients.” Medicine is an art, a science and a business. We went to medical school to learn to maximize the benefit to each and every individual whom we’re giving the honor of serving. CMS is now mandating what tests need to be run and the amount and type of treatment modality which needs to be given. This is the road to perdition. How much fluid to give requires judgment. When to do a CT scan for suspected appendicitis is a judgment. If and when TPA is required for a posteria fossa stroke is not only judgment but a shared decision-making question for the doctor and the patient’s family. These can’t be mandates from a nameless, faceless federal government. We need as an organization to defend the relationship between physicians and patients. If we do not, future generations of doctors and patients will curse our souls.