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A Modern-Day (Very) Modest Proposal

Burg, Michael D. MD

Viewpoint

Aside from the pelvic and rectal exam, I've performed virtually every other portion of the physical examination in the ED hallway. Sometimes I do it behind a screen; commonly it's done in full view of passing visitors and hospital personnel with me awkwardly reaching under patient clothing, possibly palpating but not visualizing what I'm supposedly examining. I always apologize.

Dr. Burg is the residency director of emergency medicine at Onze Lieve Vrouwe Gasthuis (Hospital) in Amsterdam, The Netherlands, and an assistant clinical professor at the University of California at Fresno.

My plea for forgiveness usually sounds something like, “I'm sorry I've kept you waiting so long, but we have no patient rooms and I just couldn't keep you waiting any longer (for medical attention, pain/symptom relief, diagnostic evaluation). Do you mind if I begin my history and physical examination here so we can get you the care you need?”

I also apologize before asking personal, probing questions of patients in the hallway while total strangers wander by within easy earshot. Patients and their families witnessing the overcrowded chaos around them always say they understand and don't mind. I do mind, but reality dominates.

I try not to do procedures in the hall, but I have repaired lacerations, applied splints, reduced fractures and dislocations, and done the A, B, C, D, and even E of ATLS there, among other things. My worst experience in this arena to date has been intubating a patient and performing CPR while he lay in the middle of the ED floor because there was no gurney available for him. I've also cared for a colleague's mother with a serious GI bleed while she sat bolt upright in a wooden desk chair with two IVs running, oxygen mask and NG tube in place, awaiting a blood transfusion. If you've not had similar experiences, then I suspect you're either extremely fortunate or relatively new to the field.

‘While emergency medicine works on solving crowding, let's offer board certification in hallway medicine’

While we work on solving our ED overcrowding issues, I'd like to advance a modest proposal.1 We need board certification in hallway medicine. It should be an advanced certificate of special achievement above and beyond ABEM certification because no part of the formal residency training curriculum addresses this important part of emergency medical practice. I looked; “Hallway Medicine” is not in the model.2

Oral and written certifying tests in this new subspecialty should be administered simultaneously, preferably in a crowded shopping mall on Christmas Eve while the physician applicant shops with at least four children under age 10. The exact material to be mastered has not been completely defined, but might conceivably be drawn from these texts now in preparation: “Creative Apologies and Explanations for the Practicing EP,” “EM Procedures Capable of Generating a Public Spectacle,” “Shotgun Medicine: Labs and X-rays as a Substitute for the History and Physical,” “Acute Abdominal Examination Through Seven Layers of Clothing: A How-To Guide,” and “Pulmonary and Cardiac Auscultation: A Lost Art.”

Figure. D

Figure. D

If this modest proposal is adopted, soon one of our colleague's nameplates may read, “Ima Harried, MD, FACEP, CRAMPED” (Corridor-Related Acute Medical Practice in the Emergency Department).

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References:

1. Swift J. A modest proposal. 1729. Available online at:
2. Hockberger RS, et al. The model of the clinical practice of emergency medicine. Acad Emerg Med 2001;8:660.
© 2004 Lippincott Williams & Wilkins, Inc.