Science, Circus & the Death of the Adverb

Ramblings of an aging mind on the conclusion of yet another ACEP Scientific Assembly  

 

As I wax nostalgic on this year’s ACEP Scientific Assembly let me begin with a word about the demise of the English language. Consider this my annual diatribe on the death of the American adverb. I’m not sure what happened to it, but it is essentially gone. As I sat through lectures, I was forced to listen to poorly joined subordinates and mixed cumulative, an embarrassment to English construction. Now I’m not expecting that everyone presenting at the meetings has the command of Samuel Johnson, but I do expect that they are able to put together workable sentences. In formal presentations, I am hereby begging people to think again about sentence structure. I understand that I am vox clamantis in deserto, the lone voice crying in the desert on this issue. I spent many years torturing my children and various medical students and residents on the issue, and as I fade quickly into the distance I will cry out once again.

Of much more linguistic interest was to see the great richness and variety of America when it comes to the phatic expression. Phatic communication was discovered by the anthropologist Bronisław Malinowski noted to be present in every communication system in the world. There are spoken phrases which have nothing to do with literal meaning but rather establish the interaction between the speakers. When you’re speaking to someone from the New Jersey chapter of the ACEP it is always wise to open up with the phrase, “How you doing?” with the emphasis on the “how”. When you respond to such an inquiry the only way to answer is to respond with “how you doing?” with the emphasis on the “you”. This has nothing to do with asking anybody about how they feel or how they are actually doing. That would be the kind of conversation a doctor would have with a patient. No, this is the way we establish the fact that we’re willing to actually stand there and listen to each other and probably don’t have our hand on a small caliber weapon in our belt. The phatic communication is repeated again and again as people from around the United States come together. It has always been strange to me that people from the south are so polite that no matter what you have to say, and no matter how stupid or inflammatory it is, they will always begin their response by saying “God bless you”. If this phrase had to be repeated by someone in New York it would be “eh, get the hell outta hear.” But they will never say that in the South; it’s always polite and always congenial. It is amazing how we can establish relationships and interact with phatic phrases, which we all understand and from which none of us dare vary.

Another aspect that brings people together from everywhere is that there is no sense of agreement. If you listened to the comments which followed Paul Begala’s opening remarks at the ACEP meeting they ranged all the way from “sounds like an interesting man” to “if we catch him before he gets out of town he’ll be tarred and feathered.” If you question that there is any confusion and controversy within the United States about which direction health care should go, just try sampling the physicians within the American College of Emergency Physicians. They run the gamut from slightly to the left of Mao Zedong to slightly to the right of Louis XIV. To think that there is some agreement on how health care ought to be reformed is childish at this level.

On a more positive note, I will say that this is probably the finest year for discussion of health care issues I have ever seen at the scientific assembly. I remember the years when it was not a scientific assembly but a coming together for mergers and acquisitions. Fortunately, the math has been done and emergency medicine has been shown to be a relatively low-profit business. It is amazing what a little intelligent mathematics will do to financial hyperbole. This year really was a series of discussions on where health care is going in the future. That said, there were some discussions, which were clearly more important than others. The look at the “workforce shortage” was amazing to hear. The position we have in regards to the manpower shortage is a reflection of where you work now and how old you are. Since I remember when there were only 1000 board certified emergency physicians in emergency medicine, I know that we’ve come a long way. Today perhaps 26,000 people have passed the boards. The integration between board certified physicians and their distribution and how they should be spread across the United States has not been determined and quite frankly has not been intelligently studied. The use of the integration of emergency physicians and mid-level providers is clearly a pathway to helping alleviate certain workforce shortages, but the number of people to study and publish on this issue is devastatingly small. The correct relationship between the number of board certified physicians and midlevel support is almost a no-man’s land where angels fear to tread.

The second issue, and one which will not go away, is the actual role of emergency medicine. Will it be a one-stop shopping center for all health care? How much should be attained in the emergency department? Is it reasonable that patients are upset that their pap smear will not be back within the hour? Is it plausible that we should expect to give people screening and advice about violence to teenagers? How much time is available per patient and how much do people want to have us do? We’re being asked to do more and more with less and less, until finally we’ll be asked to do everything . . . with nothing. As the system finds more and more things that should be done in the emergency department, someone must ask who is going to pay the bill. The resource base is simply not sufficient for the ED to be the answer to all of the health care questions on the planet.

Lastly, it is with some degree of warmth and pride that I look at the educational presentations at the Scientific Assembly. With attendance approaching 5,700, this is the largest gathering every year of emergency physicians in the world. With this rise in attendance has also come an unparalleled expansion of faculty. Having been part of the early years, and having now contributed for 30 years to ACEP’s educational programs, it is magnificent to watch the blossoming of the educational talent within the specialty. The quality of the lectures, English grammar excluded, has become superb. The variety of things available is seemingly endless and the stature of the faculty in the various academic communities around the country has grown tremendously. With all the various problems happening in medicine, health care and society in general, I believe that emergency physicians can look back on their growth as a profession as an educational venture over the last 30 years as a point of real pride.

It is when I’m with my brother and sister emergency physicians that I can properly communicate. I can use a term such as “terminal fibromyalgia” and everything has been conveyed. It is always a pleasure to gather with my brothers and sisters who understand what we do for a living, who understand that we have more in common with police and firemen in our communities than we do with the ophthalmologist and the neurologist. To come together with folks that have no concept of warm pizza and no understanding of leaving on time is a joy, a pleasure and an honor. I understand that these are somewhat bizarre and rambling comments but it reflects the Scientific Assembly itself, which is the Broadway and the Barnum and Bailey Circus of emergency medicine.