With Great Power . . .

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Power is an unusual commodity for many reasons, not the least of which is the fact that you first have to decide what it is. To my mind, the most useful definition is “the ability to influence events and outcomes in one’s favor.”

No specialty has as much potential political power as emergency medicine, but it must be used wisely.


Power is an unusual commodity for many reasons, not the least of which is the fact that you first have to decide what it is. To my mind, the most useful definition is “the ability to influence events and outcomes in one’s favor.” Emergency physicians have held a misconception for many years that they are powerless. Wherever I go, I hear physicians whine about their lack of control, or how they can’t do this or that. Stop! Shut up! You have not sat and looked at the power relationships, what power can do, and where you sit on the power curve. No group of physicians sits with as much potential political power today as emergency doctors.

Why? We are the central hub of clinical decision-making.

I was asked a few months ago to give a talk on where we will be in year 2020. To me, this wasn’t difficult at all. If you observe where medicine has been going, it is clear that hospitals will basically become: emergency departments with holding units, intensive care units, surgical suites and pretty much nothing else. Everything else will be done on an outpatient basis. Being at the center of clinical decision-making, the emergency physician will be crucial in deciding “in or out.” Do they get inexpensive outpatient care or expensive inpatient care? Those types of decisions will be critical in deciding how healthcare will progress. The second thing that will happen is that more and more outpatient physicians will stay outpatient physicians. It will be the rare internist who has admitting privileges. Patients in hospitals will be handled by hospitalists who devote their time and effort to the critically ill. This is already the case in most of Europe. No one has a cutesy practice of medicine and then shows up at the hospital at 5 o’clock to “see how their patients are doing.” This type of medicine, which is nostalgic at best and tragic at worst, is left over from the 1950s. It amazes me that although we are striving for 2011 science, we’re perfectly happy to deal with a 50s-style delivery of healthcare. It’s not going to last, and we should be the ones to make the change.


The ability to influence events and outcomes bears with it a great responsibility. There’s the responsibility to show up and get involved. Why should we take a second-place role in any discussion having to do with the hospital? Everyone is sensing the shift in power to the emergency department except the emergency physicians themselves. Having been the President of the American College of Emergency Physicians, I realize that most power is an illusion. The only power I had was getting other people committed to ideas and concepts. That is where emergency physicians need to be. We need to be on every committee at the hospital, particularly the executive committee, in order to carry on these discussions.

I now wish to discuss the rules of power, and to make certain that everyone understands that these rules don’t change. Rule number one: in words of Lord Acton, power tends to corrupt and absolute power corrupts absolutely. In other words, used in any way other than focused toward the stated goal, power will tend to interfere with good intentions. When you use power for you, you lose it; when you use it for the cause, you gain it. The only real power emergency medicine has is that we can do things for others, keeping the patients as our central focus. This is the key. Every discussion which is in a power relationship in the hospital should be identified by emergency physicians as a chance to improve patient-focused care.

Power throughout the ages has been used and abused (and been used to bemuse), simply because those who have it have not learned how to keep it. If you want real power, you must get it the old fashioned way, which is to earn it. The days of the backpack emergency physicians are over. People wanting to do their shifts and go home, never taking responsibility in the hospital, can always get such positions. But they will always work for those who are committed to a larger idea and concept, which is direction and improvement in total patient care. Above all things, loyalty and integrity will be admired by both your friends and foes alike. People who understand what the goals are and stick to their guns will, in the long run, win.

Woody Allen once commented that 90 percent of success is showing up. Regardless of your opinion of Mr. Allen, he’s right. To think that we can not be a part of the fray is to not understand what we do. Great walls crumble one block at a time, the same way they were built. To think that you’re going to get everything you want instantly is folly. Nobody does. But, to believe that we cannot make headway is a huge mistake as well.


Now hear this: the methodology by which hospitals will be paid is changing, as is what will be necessary in order to justify their financial existence. We need to lead, not follow, in this evolution. The correct utilization of personnel – how many mid-levels to staff, etc… – needs to be our area of expertise, and we need to look for financially satisfying solutions. Understand that we can’t necessarily provide perfect care; no one ever has.

But your power with administration will be in being able to show cost-effective models for staffing, treatment and ancillary services. The day of the block payment is coming; hospitals will receive X number of dollars for managing certain diseases or patient groups. The only way that we can maintain what we have and actually move to a higher plane is to take control of these situations now. It is up to us to exercise our power in producing a product that is understandable to the American public, at a price which is also understandable.

Readers of EPM know that Dr. Richard Bukata recently wrote an article called, “Slow and Expensive: Examining the ED’s Value Proposition.” This one piece shook the very timbers of the EM specialty. Dr. Bukata raised an important issue: if you want power, get in line to give the American people a better product at a more reasonable cost. If you don’t do it, somebody else will, and you’re not going to like their suggestions. In the halls of Congress and in quiet corners everywhere, people from other specialties are discussing the fact that emergency medicine and the bills for emergency department visits are out of control. If we don’t take this discussion seriously, who will? Answer this question before proceeding.

Finally, timing is everything. The economy is in trouble, and the public is tired of footing an unlimited healthcare budget only to be told that the government has overspent. Bulk purchase of services is set to drive us in a new direction. Put it all together and the timing is right for new answers. But we need to take control and have the plans ready to go to present to the federal government and major insurers.

Stay tuned for part II…

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