Rhythmic yet jaunty; harmonic yet complex – the soundtrack for a specialty.
John Adams is an American contemporary classical composer. His most frequently performed piece, Short Ride in a Fast Machine, is a four-and-a-half minute orchestral masterwork composed in 1986, and it’s a great metaphor for our specialty. It’s quick and rhythmic—far from the dramatic strains of Beethoven or the lush melodies of Rachmaninoff. Adams creates a feeling of musical instability while adhering to strict tenets of orchestration and musical axioms. It’s emergency medicine described by sound.
Short Ride’s rhythmic pulse begins with the crisp crack of a woodblock. Rhythmic accents soon enter that are in conflict with the established beat, creating a jaunty, jerky effect. Eventually, rhythms unavoidably bump into one another. Despite the jaggedness of the rhythm and near impossibility to clap along, the tempo is mechanically regular and follows strict rules of musical composition.
In the ED, physicians are interrupted and pulled in multiple directions—the nurse has a question and a patient starts to crash just as you learn that a consultant you called 45 minutes ago is waiting on hold. The rhythms of the ED are a head-spinning mishmash. And yet, the patient with a coronary artery occlusion gets ballooned well within the 60 minute goal, independent of the tempo of the rest of the ED. With starts and stops and jerks and fits, every patient receives the care they need.
Emergency Medicine is a difficult specialty to practice—our pace has the irregularity of a-fib, but the beat goes on. Emergency physicians are the diagnostic experts for the undifferentiated complaint. We are often the default problem solver for social ills and health care inefficiencies. The ED visit that is often seen as a failure by health policy researchers and payers often results in the deft untangling of a societal Gordian knot.
The harmonic structure Adams uses to initiate Short Ride begins with three basic tones. Over time, lower notes are added that change the harmonic anchor. By the end of the piece, every added note builds an increasingly complex final chord that is rich and polyphonic. The effect is a brilliant synthesis of sound.
Emergency Medicine is the ultimate care coordinator. Once derided as a “glorified triage officer,” the emergency physician navigates a differential diagnosis without the bias of seeing the patient through the lens of a single subspecialty. Somewhat similar to Short Ride, we start with three simple tones: airway, breathing, and circulation. We add a symptom-specific history and a targeted physical examination. Pre-test probabilities complement diagnostic studies, and eventually a nuanced differential diagnosis is narrowed to a single harmonious condition, replete with comorbid factors that define risk stratification. Our final diagnosis is a parallel to Adams’ final chord.
Short Ride in a Fast Machine is a challenge for the performing musician, and definitely not for the musically faint-of-heart. Likewise, EM is not for the medically timid—it requires making absolute decisions in a whirlwind of uncertainty. Emergency physicians choose to do that which is hard. We push our chips “all in” when it comes to serving the public. Instead of being guardians of the guild, emergency physicians are sentinels of medicine’s social contract with the public. Through our training and certification, we assure the public that emergency physicians are ready to care for any person needing anything at any time.
******
The trajectory of emergency medicine is astonishing. In our early years, there were acrimonious naysayers who touted that EM was not a specialty. They declared that the “emergency room” was the final professional resting place of burned-out misfits—the elephant graveyard for doctors. Emergency medicine was thought to be for “physicians who have retired from military service, are ill, or are tired of the rigors of regular practice.” *
For the “mature” emergency physician, one oft-engaged pastime is to muse about how clinical practice has changed over the past 40 years. When emergency medicine started, no one conceived of door-to-balloon as a treatment strategy for the patient with a myocardial infarction. There was a day when nearly drowning someone in a basin of ice water while mashing on the side of their neck was how supraventricular tachycardia was treated. Rotating tourniquets and phlebotomy (a modern variation on blood-letting) were short-lived fads for treating the patient in congestive heart failure.
Today, the original 5-100 American Board of Medical Specialties (ABMS) vote in opposition to recognizing emergency medicine as a specialty is a distant memory. The early resistance to EM has faded—it has become an apocryphal tale told around a campfire. For today’s emergency medicine resident, it’s ancient mythology. Nearly 40 years after the original ABMS vote, EM has become the seventh largest of the 24 medical specialties, and we are on our way to soon becoming the fifth largest discipline.
The broader world of medicine reflects the success of emergency medicine. It is one of only a handful of specialties with an endowed fellowship in the National Academy of Medicine (formerly the Institute of Medicine). Last year we celebrated the first time an emergency physician, Steven J. Stack, MD, was elected President of the American Medical Association. Adding to this momentous accomplishment was the election of emergency physician, John W. Becher, DO, as President of the American Osteopathic Association. A capstone to the year’s success is that John C. Moorhead, MD, another emergency physician, is this year’s Chair of the ABMS. Emergency physician leadership has been called upon to navigate a tempest of health care change.
As a specialty, EM is no longer in its infancy, but we are not yet fully mature. To borrow a characterization from Ben Munger, the first executive director of the American Board of Emergency Medicine (ABEM), we are in our adolescence. Physicians who became ABEM certified through the practice pathway (“grandfathered” diplomates) were once the largest group among ABEM-certified physicians. They now make up only 10% of all ABEM diplomates. Of the 35,000 ABEM-certified physicians, the baby-boomers are moving over for the Gen Xers and Millennials. Our younger generations are taking the controls of our fast machine and the results are exhilarating.
When you think about the way in which emergency physicians have transformed health care delivery since the specialty’s recognition less than 40 years ago, it truly has been a short ride in a fast machine. Now is the time to hold tightly—our second lap is just starting.
Post-Script
I cannot complete this piece without acknowledging that it is the first column to follow the long-standing essays of Gregory L. Henry, M.D. Greg is, of course, the ultimate hard-act-to-follow. It is readily apparent that this column has been an abrupt departure from the written erudition of Dr. Henry—the absence of Latin and Shakespeare is an obvious clue. As a specialty, we are indebted to Greg for his wit and wisdom and for the times when he’s steered our fast machine.
*Testimony, “Liaison Committee for Specialty Boards,” October 26, 1976. As cited in Zink, BJ. Anyone, Anything, Anytime. A History of Emergency Medicine. Philadelphia: Mosby, 2006: 165.