Dear ACEP leadership: As our national meeting approaches, continue to lean into honest, transparent debate, no matter the cost. Popularity is transient. Vision is not.
April is not the cruelest month, no matter what T.S. Eliot says. Not in Michigan anyway. Here, in the Great White North, we’re hanging up the full frontal ice suits and putting the sled dogs out to the kennels for the season. Though to be fair, as I write this piece, 19 gigantic lake freighters lay caught in the ice floes of Lake Superior. Even three coast guard cutters can’t free them.
It’s mud season, that wonderful time of year just before my jungle of a lawn starts taking up all my free time when I catch up with essential reading. This means old friends like William Blake and Dylan Thomas as well as the most recent medical journals. As an aside, my total reading has gone down over the years, but the circumspection I apply to each page has increased. Along with the peer-reviewed journals, I of course pick up the “throwaway” magazines, one of which you’re probably holding in your hands right now. These keep me abreast of the scuttlebutt in emergency medicine, and, when it’s EPM, helps me remember what I’ve said in print (which is helpful at my age). I pick up Emergency Medicine News just so that I can read what my friend Jim Roberts has to say. If there’s a smarter or more productive writer in emergency medicine than Jim, show me. He blows me away every time.
And then there is ACEP Now, formerly ACEP News. I usually do not comment on what other journals do or what they write, but for this piece I will make an exception. ACEP Now is back in the game. A year ago I would not have said this, but now I can confidently say that this publication is where it belongs. It’s again part of the “big three” and mostly because of an editorial decision to bring Kevin Klauer on board as medical editor-in-chief. As you might remember, Kevin held the same position for many years here at EPMonthly. He was my “boss” – a position relished by no man – and he managed me skillfully. Here’s a man who’s so productive that he makes everyone around him, including me, look like they’re standing still. He’s quirky, inquisitive and attentive to detail. Not to mention that he’s articulate, handsome and athletic. In short, he’s everything I’m not, and which I despise.
I don’t usually recommend you read anything but great literature – or my column – but the interview in the March 2015 issue of ACEP Now, with ACEP President Mike Gerardi, is the way professional journals should be run.
Drs Klauer and Gerardi cover themselves with both dignity and candor. It’s real. Mike Gerardi gets it. He knows that a sea change is coming and he is preparing his membership for real discussion and a real change. Dr. Gerardi actually answers questions. It’s not the usual slippery abstract language so common to high-flying contemporary elected leadership. His responses were comprehensible. No gibberish located in a “dialectic field of reference.” If truth cannot be spoken for fear of ridicule, we will concede the world to the celebrants of post-modern Confucianism. Dr. Klauer by his questions and Dr. Gerardi by his answers have resisted the ruthless Jacobean suppression of all dissent. I am proud to call them my colleagues and friends.
The company of excellent men is vanishingly small. Both the questions and the answers counter the influence of those whose credo is bold absolutism and serves as a subtle resistance to those who would be telling us there are no more major problems. They look at the new mountains we have to climb.
Today isn’t yesterday. New ideas need to be discussed. The piece, like the teachings of St. Augustine, reminds us why we all need both mercy and unclouded vision of the future. We, as an organization, will never gain equanimities by providing censored material. Honest and sincere dissent should be our goal in carrying on an organization of volunteers.
It’s not about just us, the providers. It’s also about them, the people of the United States. The old men who can no longer dream, the ragged children who never got to start on a level playing field. Our pursuit of happiness should never turn into the dead end of narcissistic preoccupation.
The real answer to self-censorship and aggrandizement is confession and recognition of what the greater good of the society should be. The real test of our effort is the degree to which we respect human dignity and whether we bring to these discussions and our limited authority a sense of both dignity and excellence and a firm set of moral principles.
The delivery of scientific healthcare as we currently understand it has gone way beyond science. It is an almost evangelical framework looking for that “sweet spot” between the theological and the metaphysical. We struggle between Nietzchean aphoristic brevity and lyrical phrases which have no meaning. We are constantly being forced to choose sides in absolutism. You are with us or against us, as if there were no other legitimate answers to the huge healthcare questions before us. When will we see that the old dualistic cosmology of the Greco-Roman era has collapsed, just as the equally dualistic thoughts of the Cartesian-Newtonian period should have resolved themselves by now in dealing with social issues. This is the new era. This is the Maxwellian-Einsteinian Age. Those modes of thought can prevail. It’s clear that we need to look beyond the various camps in which we have been divided. It’s not really them against us. This is a fight to see the future as it will be, not the way we want it to be.
Dr. Gerardi ends the dialogue with an important message: “In these times, our specialty will lead our country in creating an improved healthcare system and at the same time we will be recognized for the tremendous value we provide.” Well said. If not us, who? If not now, when? Godspeed gentlemen.
Almost 20 years ago I gave a talk attempting to set the agenda for my presidency in ACEP. Challenge to the status quo and long-term change are frequently unpopular topics. I spoke of the practice delivery mode and environment and how other models could work equally as well. I immediately made the academics angry. How dare I suggest that cut fingers and headaches could be seen somewhere else. Look where we are today. We have lost 20 years’ ground on this issue because we did not stand back and take a longer-term look at this problem. We did not understand that we needed the importance of building long-term careers and the maturation of the emergency medicine lifestyle to its logical end conclusion. It was a mistake. And now we are forced to play catch-up.
Next in that talk I put forth the central hub theory of both disease and care. It was becoming clear that doctors’ offices would no longer be sending patients to the hospital for admission, but to the emergency department for evaluation and only occasionally for admission to the hospital. That made family practice, internal medicine and pediatrics unhappy. Look around; all of this has come true.
The third point was the ridiculous nature of cost versus charge and how nothing made any sense the way it was priced. We are pricing ourselves out of existence. Did anyone even think to ask that we’re the only country in the world that does it this way and why others have moved ahead of us? We are charging $175 for putting a PulseOx clip on a patient’s finger. The total lack of transparency has made U.S. healthcare the most expensive in the world by a factor of 2.2. This comment, by the way, made the financial people, the insurance people and the administrators mad at me as well. You can see by now I had a long line of people standing in line to punch my nose.
Okay. Just like the Ginsu knives, we’re not done yet. When I get to the fourth part where I spoke about the workforce allocation, things really got hot. The nurses wrote letters claiming I was against them. As I look back, this workforce shift with utilization of techs and advanced practice providers has just gotten started and will be the largest change we are going to be called on to manage in the next ten years.
The last point I made – and which nobody liked – was the question of bulk purchase of service. If I was a bulk purchaser of a service like ours, i.e. the federal government, the state government, Blue Cross, etc., I would pay a lump sum of money and require no charts or paperwork and let the providers figure it out themselves. Why not?
As you can see, Drs. Klauer and Gerardi, the validity of the arguments and the inevitability of change does not mean that people will like your message. Popularity is transient. Vision is not. Sic transit gloria mundi.
If summer comes, can ACEP 15 be far behind? [Apologies to Shelley.] Klauer leads the Council; Gerardi represents the Board and leads the College. Throw caution to the wind, gentlemen. Lead us. I do not now, nor have I ever felt constrained by the intellectual desert we euphemistically call political correctness. For God’s sake, lead us, challenge us, discuss things. We need fewer crap resolutions and more internal resolve. Avoid the party line, which always seems to be inherently afraid of confrontation.
This question-answer piece was a great start. I implore you to carry on with the proper forums and resolutions to make real change. I beseech you to make this dialogue only the beginning. Be emboldened by Matthew Arnold and remember the landscape outside the walls of our Council meeting venue.
And we are here as on a darkling plain,
Swept with confused alarms of struggle and flight,
Where ignorant armies clash by night.
from Dover Beach, by Matthew Arnold
