I recently had the privilege of watching my son-in-law open his envelope to learn where he had matched to receive his post graduate training in emergency medicine. Having worked so hard for so many years to get to this point, I’m sure he felt both a sense of exhaustion and relief.
Every program nationwide had at least 12-15 solid applicants for each of their 10-20 openings. When these successful applicants finish their training they will go on to hopefully have promising careers. They don’t know that this was a long day in coming — much longer than any of them can imagine.
Do any young readers know why the area we have worked in all these years is called an emergency room? It’s because it used to just be one room. Many years ago, I worked at a hospital that still had that one emergency room. It was located at the back of the hospital and was locked. Patients presenting to the ER had to ring a bell for a nurse to answer and bring them in.
In some cases, trauma patients were brought in ambulances run by funeral homes. My 91-year-old father -in-law still tells stories of wild ambulance runs to car accidents in the middle of the New Mexico desert. A ride in a hearse on the way to the hospital was just the beginning of the tale for patients.
Typically, the “doctor” called to see the patient was the lowest, youngest, dumbest intern in the hospital. He, or sometimes she, actually lived at the hospital, which is why they were called “residents.” Many doctors eventually married nurses because they were the only women they met. If they were paid at all, it was a pittance. They virtually had no outside expenses.
I got to experience a little piece of this history when I reported for my training in 1979. The hospital issued me several sets of clothes — not just coats, but clothes including pants, shirts and everything … except underwear.
We were given meal tickets to the hospital cafeteria and since most of us didn’t have families, we could come eat in the hospital free on weekends.
Our education was submersion learning, which didn’t occur at the tutelage of an experienced emergency physician. It was see-one, read-one, do-one. An experienced nurse might be the only help a young frightened intern would have, a scenario I faced during my last months of medical school.
Rumors were passed around at our med school that a nearby rural hospital would hire fourth year medical students as “nurse technicians” to run their ER on nights and weekends. They were too small to even have interns so I did it. I was never more terrified.
I directed codes while glancing down at the EKGs for Dummies book. I did a Kocher maneuver to reduce a dislocated shoulder having never seen one before. It wasn’t just that I’d never seen the maneuver performed — I had never seen a dislocated shoulder. The book didn’t say anything about giving the patient sedation. I was sweating and straining so hard I couldn’t hear the patient screaming.
Another instance, I directed the staff to perform CPR on a patient for over 30 minutes, only to find out that the patient was found dead at home and only brought to the ER for pronouncement and certification. That was an awkward conversation with the family.
This is all to say that the world was ready for the beginning of emergency training in the 1960s. Patients were starting to come to ERs in droves when they found that Blue Cross/Blue Shield would pay for an ER visit when they wouldn’t pay for an office visit to their doctor.
The timing was ideal as society was getting more violent and cars were getting faster and more dangerous. Some doctors got together and created the American College of Emergency Physicians. There was actually a debate in some of the first issues of the College journal on how they should be identified. A half dozen or so hospitals decided to train emergency physicians.
All in all, it was a great time for a young medical student like me to wade into the best medical career in the world. There was one problem. Big academic institutions, like mine, weren’t ready to encourage EM careers.
When he heard I was applying to an EM program, my academic advisor actually sent a note around to my other professors suggesting that they counsel “this young promising medical student not to waste his time on a career working in the ER.” My medical school was so opposed to the notion of EM that my residency choice was not announced at the match or at graduation.
They announced I was going to Akron, Ohio…to do what? Work in a 7-Eleven? They wouldn’t say. I got my revenge many years later when I found out that my advisor, a general surgeon, had eventually gone into full time emergency medicine and had even become the president of the State ACEP Chapter.
When I arrived at Akron General Medical Center to begin training in emergency medicine with the other two people in my class of residents, we quickly learned that we would be the eternal interns. Regardless of what year of training we were in, when we rotated through other services (and that is what we did most of the time) we would take the intern’s call rotation. It was humiliating, but it was a great education.
Since I had came from Missouri, where you can sit for the Federal Licensing Exam the day after graduation, I was one of the few interns who arrived with a full license to practice medicine. That meant I could moonlight in any rural hospital ER crazy enough to hire an intern, and there were many.
In those first years out of residency emergency medicine was in chaos. Hospitals were hiring residents with one year of attending experience to be department heads. Emergency medicine groups were taking over hospital EDs where not a single doctor in the group had more than a year or two of experience.
Groups formed, dissolved, reformed, and expanded. Advances in diagnostic capability, point- of-care testing, trauma resuscitation, and much more occurred at an amazing pace. It wasn’t long before the nation went from one that didn’t know what an emergency physician was to one that demanded a board certified emergency physician for every patient.
Along with the recognition of a rapidly evolving expertise there was the reward of compensation. Since those first years out of training I’ve seen compensation double, triple and then quadruple. Today, emergency medicine is a highly respected specialty with incredibly competitive residency positions.
There has been a lot of water under the bridge since emergency medicine began so many decades ago, and the country is better for it. The expertise in today’s emergency departments is staggering. People are alive and well today for the care they receive in the nation’s EDs.
A myriad of opportunities for impact on our country’s health care system sits squarely in the hands of today’s emergency medicine residents. To a large degree they will shape the transformation of the American health care system in the future.
My hat’s off to all the medical students who have received one of those coveted training slots to begin their training in earnest for a career in today’s emergency medicine. They are smarter, more compassionate, more savvy, and more forward thinking than I was at their age.
But there is one thing they may not know. When they sit where I do now, the field will have changed just as much as it did in my career. It’s hard to even imagine.
Your career in EM sounds like mine as a PA. I became a PA when no one had a clue what one was. I would order a CXR and the radiologist would refuse the order since I wasn’t a doc. Those were the days. I remember the first mammogram I ever ordered, because the woman came back to the office and said I had saved her life. And that was only a few days after the CXR debacle.
So, you didn’t tell us the last page of your son’s-in-law journey. Did he get what he wanted?
I note with great admiration the “trailblazer” career of Dr. Plaster and the wonderfully chaotic years of his baptism by fire in the “ER”. I came to EM training a few years later (1985) and after completion of a Family Practice residency before entering a well established EM training program. My “ER” experiences as an FP Resident though were hilarious as his as I too, came into Intern year as a licensed physician and dove into moonlighting (1982) . I felt well trained in the breadth of medicine but was quickly challenged by the ring-the-buzzer one room ER, the 3 critical car accident patients with no back up, the weird and “they didn’t teach me THAT” of removing stuck objects in human orifices etc. etc. I couldn’t get enough of it and knew the writing was already on the wall to be best served by an EM residency so I burdened my family for a few more years but came out a better person and doctor because of it, albeit bruised a bit. Whereas Dr. Plaster embarked on a distinguished Military career I practiced a mix of Academic and private and eventually worked for nearly 12 years overseas as an ED Director, educator and clinician giving my family a world view and helping a major European nation develop EM as a speciality. My pride of EM is keen and certainly we have made great strides since the days of Dr. Plaster “coding” in rigor mortis mode. I fear, however, I have lost the zeal, lost the confidence that this specialty can overcome the forces that have overtaken us ,seemingly so rapidly. We let control of our destiny, our practice and our values to be taken over by CMG’s, Administrators, government forces (CMS etc.) insurance companies and others. We more frequently replace compassion with greed, contracts over fairness and justice and productivity over personal, physical and mental health. We have let the public and the “market” determine what is medically needed or appropriate in a consumer environment that has caused costs to soar, medicine to be less caring and personal and the highly- trained, brilliant -coveted -EM-Residency -trained -physician subject to immediate dismissal without due process on a whim. We have allowed some of our physician colleagues, (who organized Emergency Medicine fought for so long to achieve their recognition), to use us as 24/7 surrogates often doing care they do not want to do but we shouldn’t be doing. We have become “jacks of too many trades” in that respect. And speaking of respect, how does that storied EM history and your expert Residency honed clinical acumen help with your local Hospitalist at 10 PM? The Emergency Department itself, once OUR domain even if it was just a “room” , is now used by an entire health system as a dumping ground for every social problem or situation imaginable and you have no say in the matter. (Here Doctor, sign this….) The volumes soar, the demands increase and yet, Hospitals and CMG’s cut staffing for both docs and RN’s, push for higher RVU performance and Press Gainey scores. This week it was announced the Medicare Payment Advisory Commission (MedPAC) will propose to Congress a 30% reimbursement cut to free standing/‘mini” ED’s which for many hospitals is a keystone of their growth plans…and the work place of many EP’s . So as the challenges increase I believe our Specialty needs a fundamental and perhaps a bit radical reset of sorts. We need the new breed to take a hard look at the Specialty they have embraced and do not be afraid to openly challenge the status quo. Looking back with pride and nostalgia on our accomplishments is not enough. It will not be enough for those talented and energetic Match Day doctors.
I have enjoyed reading your columns for many years. We were actually residents together at AGMC at the same time. I graduated from Ohio State in 1979 and Akron General was my first choice, although in Ob-Gyn (don’t ask me what I was thinking). Dr. Cook was the chief of Ob-Gyn, and a terrific and very funny guy. The first year was a rotating internship, and during my ER rotation, I realized that’s what I wanted to do. I tried to change programs, but Gus Roussi nixed that idea. I had taken my Ohio boards right after med school, and moonlighted during my internship doing physicals at a chain of weight-loss clinics. I left after the first year and worked in a couple of smaller ER’s for a year., then was lucky enough to join a group in a large suburban ER where I stayed for the next eighteen years, getting my board certification via the practice option. I moved to Florida where I worked for the next eighteen years. Looking back, it was frightening to be taking care of pts pretty much clueless for the first few years.
Anyway, stay well and keep writing.