Reflections on the 2011 ACEP S.A.

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altDemocracy, like love, is often blind, lacking cool objectivity and critical distance. But the deepest truths are written in braille. If the directions which our profession should take are not felt, they are not truly internalized. This country is in trouble, and I’m a patriot. But a true patriot weeps more than he brags.

EM’s largest annual meeting provides an opportunity to examine the five major areas of healthcare policy.


“Let us sit upon the ground and tell sad stories of the death of kings.”
From Shakespeare’s Richard II

Democracy, like love, is often blind, lacking cool objectivity and critical distance. But the deepest truths are written in braille. If the directions which our profession should take are not felt, they are not truly internalized. This country is in trouble, and I’m a patriot. But a true patriot weeps more than he brags.

We’re facing problems the magnitude of which we have never seen. We are, with a very thin veneer, Greece. The principle difference between us and Greece is that the Greeks have the Parthenon and we don’t. But when it comes to having signed checks which we cannot cash, we are their equal in every way. What remains most disturbing is that the medical profession is littered with shop-worn conspiracy theories and accusations of political agendas that pervade the thinking of a large number of our members. There is a perpetual blame game that takes place rather than an objective search for answers. The good old days are a time more often remembered than experienced.


Grow up. The world and medical care have changed. Sitting around wishing for the return of unfettered and unquestioned authority in health care is about as useless as sitting around wishing for the return of the buffalo and the nickel Coke. These are the wrong lyrics and music for our time. It’s like a polka band playing the Lady Gaga songbook. The notes are right but it just doesn’t make any sense.

Hypersensitivity is the surest sign of mediocrity (and there was certainly plenty of hypersensitivity at the ACEP meeting). Just as an aside, more people wanted to bitch to me about my wine selections in Risk Management Monthly and my syntax and grammar in this column than the substantive issues which I try to write about. But that’s freedom of speech, let it reign forever. God protect us from the gerund hounds and those who have studied Eats, Shoots & Leaves.

We have entered a perpetual intellectual middle age in emergency medicine. We have shorter hair and better sport coats than we did 35 years ago, but I’m not sure we have the same sense of focus and purpose as our founding fathers. Fortunately we are now only reading the resolves and not the whereas’s on commemorative and memorial resolutions. Sit tibi terra levis should be sufficient for all those who have died or retired from the organization.

What was not adequate at this year’s ACEP meeting was the discussion of the real tools we have and need to help shape healthcare policy in the future. There was a good panel on this issue that lasted about an hour. That’s not enough. This is a part of the a priori versus a posteriori debate we have taken as an article of faith. We are in a serious need of a neo-Kantian revisionism. We need to understand what frame of reference informs our discourse. Using models which I have presented in this column in the past, I wish to touch on where we are in the five principle areas that make up health policy.


To some degree, science, over the time of the council and the educational offerings at the Scientific Assembly, was discussed. But it should be noted that there is no major change in science that informs the delivery of health care. There is no magic pill. There is no new therapy. There isn’t anything obvious on the horizon that will change the cost of health care or the quality of its results in the near future.

It was reemphasized again that 99% of dehydrated kids don’t need an IV. It was pointed out that the NG tube has essentially become an instrument of historical interest only – it’s a medical version of the blunderbuss. Science continues on, but it seems that it tends to reinforce the position that we can do more and more with less and less and have the exact same outcomes.

The legal environment was also discussed. This is like a straw man at any meeting. You get to throw him up and everybody gets to beat on him, but it has minimal effects in the long run. In a nation that has a Democratic president and a Democratic Senate, chances for meaningful tort reform at the national level are two: slim and none.

It was pointed out, however, that we as a specialty have made tremendous gains at the state level. Changing the standard of care – that measure against which the emergency physician is judged – is the single most inventive and useful action which has been taken at the state level in many a year. Those states which have successfully convinced the Legislature that the emergency medicine milieux is different than standard elective office practice have found excellent relief from many of the problems which malpractice brings people. The medical legal environment continues, but we are, at the state level, making some inroads.

The third major area that we need to comment on are the services provided. Last year I was honored to chair a committee which discussed end-of-life care. Not only did that two-hour panel of superior emergency physicians bring this issue to light, but this year it appeared on the agenda as a regular course offering. More to the point, a resolution was presented and passed in the council that directs the college toward investigating those things that we can do in emergency medicine to help in this dilemma.

The end-of-life care issue is the issue of our time. Does someone brought to the nursing home with dementia and a feeding gastrostomy tube need treatment for their pneumonia? If we cannot answer this type of question there is no way we can plan intelligently for providing healthcare in the future. It still boggles the mind that the United States is the only major Western country that hasn’t had a serious, dispassionate discussion about this issue. Demonizing the discussion by calling it “death panels” leads us nowhere.

There is a point in time where meaningful life is not restored no matter how much money you provide. The council is to be commended for bringing this action to the surface. But even in this moment of intellectual triumph it should be noted that the resolution needed wordsmithing so that there would not be any offensive language, such as “looted resources” in the resolve. This sort of thing, it was felt, might frighten the American public. Get real! The American public needs to be frightened. They need to be quaking in their boots about the fact that we cannot pay our bills and that over the next five years, if you don’t like what’s happening in Europe now, just wait for here. But the linguistic compromise was produced and we’re moving on this issue in the right direction.

Clearly the most volatile and important issues revolved around the question of workforce – not just the usual academic mantra that we need more training centers, but exactly who should be providing care. The hallway discussions were the best. It was pointed out that in 1972 emergency medicine graduated one person – Dr. Bruce Janiac – who had the words emergency medicine on his diploma from residency. This year, between MDs and DOs, we will graduate 1750 emergency physicians. And we are on track in three years to have 2000 graduates per year. Is this important? Absolutely.

It needs to be factored in with the fact that the day of the physician assistant is rising. Hallway conv
ersations, again, were the best. Several major groups in California openly discussed the fact that 40% of their visits last year were seen by PAs. Should this number be 60%? Should it be 70%? The largest single issue in emergency medicine costs is workforce salaries. Why hasn’t there been any true experimental model to shift staffing patterns and find out whether care is actually affected?

This isn’t just about doctors. This is about nursing, this is about techs, this is about other ancillary personnel who might be useful in providing a reasonable service at a much lower cost. There is a delusional aspect in the country that if we ignore this situation it will go away. The tragedy may be when we have emergency physicians who are looking for work. To not at least carry on reasonable discussion on this issue is a mistake.

There was an interesting combination of both medical legal and workforce expressed in one of the resolutions. This openly addressed the fact that litigation stress is particularly damaging to young physicians and that we are affecting the lives of these physicians by not intervening and helping them handle such stress. Those who have not been sued do not understand the emotional cloud under which the physician lives. Everything changes. I applaud the young physician section for bringing this issue to the table and forcing us to look at this as both a workforce issue, a medical legal issue and a wellness issue. The long-term effects of this resolution may be greater than we have ever anticipated.

Last but not least, of the five major areas of healthcare policy, finance was discussed. We live in sea of uncertainty. From the plenary opening address through multiple programs at the educational courses and at the council meeting, nobody knows anything. The chances that the current health plan put forward by the President are going to be implemented are slim to none, but what’s going to be the answer? And what are going to be the responses of organized medicine? We cannot sit around simply feeling bad for ourselves. We need to have programs that will handle this at all levels.

What really bothers me is what we don’t say about the people we take care of – simply the fact that they’re people. We have reduced them to facticity. We miss everything that makes them interesting and that distinguishes them from each other and from ourselves. We refuse to let them challenge us and perhaps judge us with their own voices. The more we speak of them en masse, the more Orwellian the tone of the discourse. Antaean power of the state only deludes our ability to treat them as individuals. Duns Scotus was able to see the wonder in the individual. Why can’t we? As we survey the provider landscape we forget – or suppress – what Gerald Manley Hopkins called the “inscape” of everything. “In our everyday experience,” writes Yuval Levin, “the bureaucratic state presents itself not as a benevolent provider and protector but as a corpulent behemoth — flabby, slow, and expressionless, unmoved by our concerns, demanding compliance with arcane and seemingly meaningless rules as it breathes musty air in our faces and sends us to the back of the line.” It has caused most Americans I know to fall into a kind of spiritual failure, consigning them to less grounded and meaningful lives, the medical equivalent of the Soviet Union.


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