Advanced practice providers are becoming a mainstay in the emergency department, but are we turning away from EM’s founding principles?
Recently I was arranging a memorial lecture in honor of one of the founders of emergency medicine. As I thought about this extraordinary person, I reflected upon his body of work, his leacy, and how we have safeguarded it.
In November 1954, Robert H. Kennedy, MD, gave a speech to the American College of Surgeon’s Clinical Congress. In it, he described the ‘Emergency Room’ as the weakest link in the treatment of trauma patients. The ensuing years brought increasing public awareness that the people who staffed the emergency room were not well trained. The country was alarmed to find that gynecologists might take care of a heart attack and ophthalmologists a trauma case. These physicians had four years of medical school, a year of a multispecialty rotating internship, and whatever additional years of specialized training they had received. They were not qualified. What was needed was someone who was trained to care for the broad spectrum of patients and complaints that populate the emergency departments at all times of the day and night. Emergency medicine was born to fill that need. The founders struggled for many years with the House of Medicine to recognize emergency medicine as a specialty. This specialty status was conferred on September 21, 1979.
The struggle then turned to the local recognition of the nature and value of emergency medicine. The medical staff and the general public needed time to begin trusting the physicians in “the pit.” Many years and countless patient and physician encounters have changed the perception of an emergency physician from inadequate to that of trusted colleague and caregiver. Through our collective efforts the emergency department has evolved into the nexus where patient meets hospital. Getting to this point has been arduous, and we still have some headwinds, but we accomplished most of our important goals.
It took 37 years to arrive in our current situation. It is a success story, to be sure.
Fast forward to recent times. Corporate medicine and contract vicissitudes are common, we are evidence driven, we are safety conscious, and above all, we are the leaders of all aspects emergency medicine.
Now the era of the ever-expanding physician extender has emerged in emergency medicine. Why are physician extenders needed? I doubt that anyone assumes physician extenders are better providers than emergency physicians; rather, they are cheaper and, since there are not enough emergency physicians to go around, we must need them. A similar argument was advanced in Missouri when it proposed assistant physician status to medical school graduates who did not match into residencies. They could practice in rural areas after one month with another physician monitoring them. Is it better to have an inadequately trained caretaker or none at all. This is a recurring question in medicine. Every graduate of medical school knows that four years is not enough training to practice medicine. More training to build on the 4-year knowledge base is required. The “emergency room” physicians of the 1950s and 1960s who so appalled the public had four years of medical education before they even had any opportunity to do clinical work. Then, they had additional and varying degrees of patient care training. Despite this training, they were deemed unqualified. Are extenders better trained than those physicians? In fact, are extenders necessary or are they expedient? Extenders are not hired because they provide better care than the physicians they replace. Better care is not what drives their use. They are cheaper to hire than physicians and create a fatter bottom line.
Patient safety is one of the most important topics in emergency medicine. It is inherent in our emergency culture and continues to be driven by federal mandates. How is it safer to have physician extenders and not physicians evaluating emergency patients? We covered this ground 50 years ago. We have already established that emergency physicians who were trained for the job provided the best emergency care. When did that change? When did we start believing someone with far less training could practice our specialty? Did the founders of emergency medicine just not grasp the business of medicine well enough? Perhaps the founders got it all wrong. Does the haze of 1960s idealism now in more enlightened times unfetter us?
In the beginning…there was a need for qualified emergency physicians to see emergency patients in the emergency room. There has been and will continue to be a relentless change in medicine and life, but some things are timeless. The enduring and appropriate concept from the 1960s is that: properly trained emergency physicians matter. This must be our unwavering principle.
Emergency physicians provide the best patient care in emergency departments. We were once committed to this concept. It is time to recommit.