Answer the Question!

To those would-be ACEP leaders running for election in the fall, I’d like to pose a series of questions about where our specialty is heading. 

In the last column, I provoked multiple emotional responses. I had no idea that commenting on the death of my dog would provoke such an outpouring of condolences. My sincerest thanks for your thoughts. Secondly, my challenge to those who will be ACEP councilors caused more than a few phone calls to be exchanged. How dare I challenge the ancient and honorable tradition of letting harebrained ideas dominate council time? How dare I suggest that coming together for endless cocktail parties and often useless committee meetings is the best use of the amazing talent which is assembled once a year for two days only at this august gathering?

We need more town halls and sessions examining our own specialty. The direction of our training must be examined, as should the practice patterns which have become sacrosanct for no good reason. In the 70s we wanted to become a part of organized medicine. In the 80s we fought with organized medicine. Unfortunately, now we’ve become organized medicine.

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Let’s be honest. Most people who are members of any organization know almost nothing about what that organization does or how it really works. Ask any resident how council delegates are elected and I bet you less than five percent will know the answer. Ask them what the RUC committee does in Washington and whether ACEP has members on that committee. Go ahead, I dare you – ask them. This is not a tirade against the young but a condemnation of ourselves. Nothing dates a man like belittling the young. But this is more complex than that.

In all organizations about five to ten percent of people do 90 percent of the work. We need our gray hairs to provide perspective and historical insight about what we have done. But without aggressive headlong involvement of the young, we will not be able to maintain our position and move ahead.

Adlai Stevenson understood a truth which we have forgotten. That truth is: Nature is indifferent to the survival of the human species . . . even Americans. To put it bluntly – which is the only way I know how to put things – I contend that no citizen really cares what the training or board certification is of his healthcare provider, as long as that care is being provided. We are losing the spiritual hunger to show the way, to create something out of nothing, to lead the greater citizenry in an understanding of the truth of healthcare. We’ve forgotten how to give insight into how healthcare is given and for what reasons. No matter what Nancy Pelosi says, the U.S. has never had a serious debate on how healthcare is provided and what care is given. We wasted our time during the Obamacare debates talking only about money, never about the care. But I, like Adlai Stevenson, “Believe in the forgiveness of sin and the redemption of ignorance.” We can turn this ship around.

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We need to be intellectually ambidextrous. We must deal with medical insights that actually advance patient lives and the broader implications of our efforts (i.e. costs, resources, etc.) on the society at large. There must be some explanation as to why we get four times as many CAT scans as the Canadians and they live longer. It’s like we’re afraid to look at ourselves.

From an organizational perspective, we need to direct the research to more pertinent lines of the healthcare debate. Our job is to produce real information, not put more lines on the curriculum vitae of people who don’t need it anyway. We need to insist that we get answers to larger questions on key issues. A free society (or organization) requires debate. The true test is that we should be a place where it is safe to be unpopular. You are not a free organization if that only includes the freedom to stagnate, to live with no vision, or to have aims so low that your only real interest is simply continuation of your income.

To proselytize on any one issue defeats the purpose of a balanced organization. But I set forth for your consideration a series of questions which we would like to ask those people who are running for leadership positions (the Board and President Elect) in ACEP over the next few months. We will be posing these questions to those who wish to lead us. The first and most fundamental is this: “Why should I follow you?” Put another way: “Where are you going? Where are you taking us? What is your vision of the future of EM?”

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I really don’t care how articulate the responses are. It’s the thoughts behind them that matter. I believe that the foremost responsibility of those running for office is to give answers – dare I say testimony – under difficult interrogation. We need questions answered honestly and willingly. What we don’t need is political correctness, the kind of feckless drivel that gets people made Garden Club president. If you have only politically correct answers, you’re probably not solving any problems. Take this quagmire, for instance: Who should be in the emergency medicine tent? Are you in favor of several classes of membership: Mid-levels, EMTs and doctors running urgent care centers? If your responses to hard questions do not upset a few people, you’ve probably said nothing at all.

Question number two: What do you think of the movement toward “EMS practice”? What are the financial implications? What are the driving forces? Where is the money? Where are the backers? Where are the borders? Where’s the political power in this new movement?

Question three: Where should ACEP be on the issue of mid-level supervision? If no real supervision is needed, why do they need a physician signature at all? What about people who are lying about such supervision? Be honest, you know it’s going on every day. If we can remotely supervise everyone, what is the current role of emergency physicians and how should we vary and change our training in the residencies?

Question four: Why has ACEP had essentially no effect on reducing costs in emergency medicine? What will you do to make a headache visit cheaper in America?

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Question five: What is the role of urgent care centers in America? What should they be doing in an era of a volume-driven business?

Question six: Since each residency graduate is the potential competitor of every other graduate, are there too many residencies? And how do we know what that magic number is? How do we know when we are eating our young?

I would like your input on these questions and others you would like to ask of potential ACEP leaders. You will notice that almost none of these questions are on anybody’s research agenda. And yet it is the exact data we need to carry on real discussions in both Washington and Dallas and in Chicago with the AMA.

As I was penning this missive, a colleague pointed out the danger of my reducing these thoughts to writing: “Maybe you will give our enemies ideas!” Sorry, they already have ideas. What we need are answers, counter measures as the larger chessboard of medicine continues to move.

Finally, when these would-be ACEP leaders answer our questions in the pages of EPM, I want your BS meter turned on. It should start pinging when you hear phrases like “out of the box” or “core competencies.”

I’m reminded of a June evening when my wife and I found ourselves at the Marriott Marquis in Times Square. Being nattily attired, we proceeded to the bar at the top of the hotel for a drink. I noticed that the stairs to the second level of the bar had two enormous gentlemen in suits with clipboards who were blocking the way and checking a guest list. I asked our waitress what was happening. She replied: “Mr. Marriott is having a private reception for his best clients.” I said to my wife: “Would you like to have a drink with Bill Marriott?” She replied: “We can’t do that.” “Oh, yeah? Just watch us.” So we strolled over to the bouncers and I said: “Sorry we’re late. Is Bill still here?” His reply: “Of course, Sir. Go right up.”

We talked with people for hours and I even asked the bartender for Remy Martin VSOP. He looked down the bar at Mr. Marriott, who nodded “yes.” “Thanks, Bill.” The point is we were able to get by in a world where we didn’t belong with a few key phrases. “I’m the Six Sigma Advisor,” “We manage the entire TQM/CQI process” or my favorite, “I’m assessing the current risk situation.”

So a message to would-be ACEP leaders: Save your catch phrases for crashing a wedding or scoring some VSOP. I want someone with the guts to say: “I don’t know. But it is an interesting question and I will find the answer.” That at least shows some honesty and some integrity.

Incidentally, after our soiree at Bill Marriott’s invitation-only party, my wife asked: “What would you have done if you got caught?” “Simple,” I said. “I’ll tell them my name is Rick Bukata.” I’ve always found it much more fun to ask forgiveness than permission.

“Change is inevitable. Change for the better is a full-time job.”

-Adlai Stevenson