From the exhibit floor to the council meeting, musings on emergency medicine’s biggest circus.
F. Scott & Zelda Fitzgerald’s tombstone contains the last words from The Great Gatsby: “And so we beat on. Boats against the current, borne back ceaselessly into the past.”
Indeed, we all, at times desperately, try to move forward against forces that somehow seem to blow us back to our roots. Fitzgerald also wrote: “There are no second acts in American lives.” On this point, I humbly but fervently disagree. Just several weeks ago in Chicago at ACEP 2014, I watched second, third and even fourth acts playing out over and over again. Indeed it was my 39th ACEP Scientific Assembly and the 35th year in a row that I attended as a speaker.
Before I begin my usual self-indulgent harangue about the resolutions sent from the Council Meeting to the Board, let me present some random impressions of our annual display of emergency medicine power and opulence.
That’s right, I said opulence. We are a medical specialty with a rise in position and prowess like no other. We are no longer a collection of uncertain, second career physicians with more bravado than knowledge. We assembled in Chicago this year as a specialty that had come of age. We have become important and relevant leaders in the medical community, counting among our numbers the president-elect of the AMA.
But with such tremendous visibility comes enormous potential vulnerability. Our actions must now match our importance (even if it’s only our own self-importance). Nietzsche, a stern critic of culture in the United States, hated us for failing to give sacrifice and discipline their proper roles. Obviously, Nietzche never knew any emergency docs.
The ACEP Scientific Assembly, besides being the best collection of toys, lectures and committees in the emergency medicine world, has become the new platform for finding out who we really are. We posture. We strut. We can be cliquish and hang-out with our fellow superheroes. This is where everyone around us gets the inside jokes and feels the pull of being in a utopia of our own making. However, like all utopias, this one will have a body count. Just look at the number of empty chairs on the third day, and you realize the EMRA party had taken its toll.
Speaking of EMRA, I’d like to thank them for electing me to honorary membership this year. You can’t imagine how touched I am to receive such an honor. This not only allows me to stop sneaking into the residents’ party uninvited, but makes me feel truly a part of the family.
Going into the small ceremony, I met a resident I had taught when he was a senior at the Wayne State Residency Program in Detroit in 1976. He was about to retire this year, and he took the time to parrot back to me some of the words and phrases that stuck with him from my lectures. This is my definition of joy — no other reward is needed.
The energy at the meeting was palpable. Most of us are geeks of one form or another and are forced to act restrained and dignified in our roles at home. But at ACEP, we can be idiots and do and say things that might not play as well at home. We can dance until dawn and then geek out over new research. It’s “club kids” meets “Revenge of the Nerds.” And I get to see the line outside my lecture hall and feel like a celebrity for a day. It’s an amazing rush, and it’s a whole lot cheaper than therapy.
In case it wasn’t abundantly clear, I absolutely love going back to “the Meeting.” For me, it’s like Cheers. It’s where everybody knows your name. Remember, we are all born superstars. Some of us just work hard to repress it.
Now on to the ACEP Council Meeting. Without invoking a “Felix Culpa,” let’s look at resolutions that really stand to impact emergency medicine, the medical specialty and its power.
The commendation resolutions are ever-present but always needed. The number of our past leaders departing this earth increases yearly, but we should never forget that we stand on the shoulders of giants. May they rest in peace.
2. Heal the World
Then there are our usual attempts to fix the world. It’s hard to be against “Safe Citizen Day,” “Sexual Assault Victims’ Rights,” “Human Trafficking” and “The Prevention of Pedestrian Injuries.” Try and build a coalition against motherhood and apple pie. Unlikely. All those resolutions went through rather easily.
3. Up in Smoke
Decriminalization of marijuana again went up in smoke. And attempts by small segments of the membership to get involved in academic internecine warfare also fell on deaf ears.
4. Changes to Triage
There were also real and important issues passed on to the Board. For example, an interesting resolution about cutting down triage screening questions was approved. I love this. Every “cause” has a series of questions they want asked at the time a patient comes in for emergency care, as if we had nothing better to do. They believe that the real center of healthcare for all people and all problems on this planet should be the emergency department. I’m surprised that there has not been a fervor to stamp out prickly heat and to have us do screenings as patients enter the emergency department — even before they’re examined for ankle sprains. Enough is enough. And if you want great through-put times and increased patient satisfaction, you can’t continue to ask every 90-year-old woman from a nursing home whether she feels safe in her environment. Get real. What happened to physician and nursing clinical judgment? No one ever does real research as to whether any of these questions actually does anything or any good. And, really, would these questions actually pick up any disease or problem that a competent physician or nurse would not intuit in the visit?
5. Giving Naloxone to Families
There were two resolutions passed to the Board which may be good ideas in theory, but carry some danger down the road. This has to do with providing families the medication Naloxone to take home with them to use on a family member who stops breathing again due to opiates. With my medical/legal cap on, I wonder if this creates an expectation or even an obligation on the part of emergency practitioners to provide such care. Just a thought for the committee who will review this policy.
6. Questioning Anonymous Expert Testimony
The Council saw fit to direct the Board to pursue the question of anonymous expert witness physicians for State Medical Boards. We need to pursue this. If a physician is going to speak against another physician’s competence or morality, they should have the guts to speak directly and show their face. If you lack the courage to put your name on an accusation, maybe you shouldn’t be mouthing off at all. We need to be able to defend ourselves from the morally superior who don’t have the courage to use their names.
7. The Telemedicine Revolution
Another potential deep water issue: The resolution directing the Board to create a policy on telemedicine — which affects everything from residency slots to supervision and payment. Now we are talking about things that are immediate, potentially devastating and under our control — where forces outside emergency medicine might actually listen to us. What a concept. Sorry folks, these things are real. Who does the remote supervision? Who gets paid? When things go bad, who goes to court?
This is an issue everyone needs to watch because Urgent Care Centers, not just regular ERs, will be involved. This deals with a question on which no one has been willing to show leadership — the supervision issue. Who should do it? And what is it worth? And as always, who is liable? Everyone wants to sail the financial ship in fair weather. Where does everyone go when the storm attacks?
8. Assistant Physicians in Missouri
A very unusual resolution – number 18 — went from Council to the Board about a specific state and a specific problem. Governor Jay Nixon of Missouri had approved a special licensing pathway to allow graduates of medical schools who can’t get into residencies to carry the title “Assistant Physician” and carry out specific duties. This opens up healthcare to examination on many levels, all of which will involve Emergency Medicine. If PAs can staff rural Emergency Departments, why not these folks? Can they serve in the ED with “real doctors”? If they do so, what do we call these people in front of the patients? And what do they get paid?
Speaking of the resident workforce, the Emergency Medicine Residents Association now has more than 13,000 members. If you factor in the three and four-year programs, you’re looking at about 4,000 graduates a year. Do the math, people. We need to do some real work on this issue. This resolution is the canary in the coal mine, and our Board has been told in no uncertain terms to lead on producing real numbers on this unusual issue.
9. Associate Membership in ACEP
Equally important was the resolution passed to have the ACEP Steering Committee study the ramifications of an associate category of membership in ACEP for those people interested in Emergency Medicine but who will never qualify for full ACEP membership. This is for the rural GP who covers the ED 10 hours a week. There would probably be reduced dues-paying. And these non-voting folks could have a chance to belong.
News flash for anyone out there who thinks ACEP is a credential. It is not. Nobody at a hospital has ever asked about your ACEP membership as a job requirement. We are a professional organization whose unifying interest is emergency medicine. We have good members who moved on to urgent care work who we should have retained. We miss them and their dues dollars. ACEP is advocacy, not employment. Get this part right in any discussion of what associate membership may mean.
10. Questioning the ACEP Gag Rule
Lastly, remember when I caused a little bit of a stir by offering (not threatening) to interview people running for the presidency and board of ACEP? This was debated and a fair hearing was given. I lost this one. But really we all won. Everyone is on notice that the process requires openness and that we need a forum to debate the issues of our time. I pledge to my readership that I will continue to ask tough questions and give no quarter to weak answers. I have no interest in going quietly into the night while there are real problems to solve in this specialty.
Qui tacet consentit – silence gives consent.
Come for the Lectures, Stay for the Carnival
by Michael Carius, MD
With the ACEP spectacle growing every year, it’s worth carving out some dedicated time to see the gadgets being hawked on the exhibit hall floor.
Close your eyes and it’s like you are at the midway of a state fair. The people, the trinkets, the aromas. The variety of exhibitors in the ACEP trade show is huge. The number of pharmaceutical firms seemed to be down – a consequence of the Sunshine Act? But this was more than made up for by an increase in contract management groups and other recruiters, ultrasound manufacturers and providers of EMRs. Then there were the shoes (really!), the body lotion, uniforms and massage chairs. The portion of the exhibit hall devoted to “innovateED” has been greatly improved and should continue to showcase state of the art products used in the practice of EM.
In fact, these displays of new technology and trends are so engaging that the case could actually be made to skip a few lectures in order to spend some time in the exhibit hall. Here’s my recommendation if you find yourself at ACEP 2015 in Boston: Plan to spend no less than 4 hours in the exhibit hall. The hall can be overwhelming, so I recommend that you do a relatively quick reconnaissance walk through all the aisles of exhibits on day 1, noting which ones you want to return to for further exploration later. This should take no longer than 30 minutes or so. Then schedule several 30-45 minute sessions targeting those specific exhibitors that you marked down as needing a more thorough exposure, say 5-10 minutes each. That way you will experience the pleasure of the whole exhibit floor as well as the more intimate knowledge and experience from a chosen few of the vendors.