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Second Opinion

Second Opinion

Where is Emergency Medicine's Martin Luther?

Leap, Edwin MD

Author Information
doi: 10.1097/01.EEM.0000456992.59345.98

    Emergency medicine is its own religion. Our profession grew out of a pressing need for physicians who could provide immediate and life-saving care to the sick and injured at all hours of the day. Our founders' goals were to ensure that we did the right research, learned the right skills, and brought those abilities to a nation in dire need of high-quality care in times of crisis. The early disciples, deeply committed to the early statements of faith, brought many into the fold. Our creed might have been: “I believe in saving life and limb, anytime and anywhere, with all the skills I have. I believe that the doctor is accountable and responsible for leading and acting to accomplish this goal.”

    Our catechism? Our first Communion? Residency, oral, and written boards. Our sacraments and liturgy? History, exam, intubation, chest tubes, central lines, and charcoal. We held sacred that we were accountable for patients above all. Humans dwelled at the center of our act of worship. We even accepted the idea that no one should be forced to pay for that care.

    The gray on my head testifies that I have been a believer long enough to see the transformations that have led us away from our true faith and into heresies that blur the ways of old. Our religion thrives on one level. Like shiny mega-churches, our residencies are the envy of many specialties. Medical students clamor for the excitement and immediacy of the ED. Maybe they sense the apocalypse, and want to be on the right side when the end comes. Perhaps our residents have prophetic gifts. America's health care system is in barely--controlled collapse right above its emergency departments, which will be the only thing to carry the day when the dark ages of medicine finally arrive.

    The science, the medicine is good. We do amazing things. But we have polluted our faith with too many rituals, dogmas, and liturgies. Our believers are burdened with unyielding laws.

    The rites of passage now? Yearly tests, yearly fees, tests each decade. Immersion in evidence-based everything to prove that we are skeptical about the right things. More documents to show that we are true acolytes. Forms to show we make people happy and attestations to prove we're studying. Systems to show that we've squeezed all of the money out of every paying patient. We worship new minor deities in check boxes, decision rules, systems, and consultants.

    The sacraments? They include more and are more complex. Time-outs, more passwords than we can recall, warnings to check drugs, questions about whether we're allowed to see the chart, impossible algorithms for admission of the sick. We honor pointless pain scales, we cringe in fear of violating EMTALA and HIPAA. We sing praises to meaningful use and add more because humans are less important than ever. We have a priesthood of administrators and consultants, federal regulators and rule-makers, and state board functionaries and hospital overseers, the cost of whose collective salaries dwarf ours.

    The early missionaries are eclipsed by armies of men and women dressed in the vestments of a profession they barely understand but are happy to run. People who want to work “in medicine” but never walked the Via Dolorosa of lonely hallways and endless shifts. Some did, but found greener pastures in collecting indulgences from the rest of us.

    The new creed is now, “I believe in saving life and limb at all hours of the day, and I will do it no matter how maligned I am. I believe everyone who says “emergency” has an emergency. I believe I must respect the bad choices of all, never condemn, never judge. I believe I must be attuned to satisfying customers and to giving credence to everyone placed above me, whether nurse, secretary, or administrator. I believe I must work long and hard as an employee and never complain. I believe forms and computer screens deserve my full attention. I believe capturing billing data is as important as comforting the sick. I will do as I'm told.”

    The creed is more complex, and we are widening the gulf from our origins and empowering the churchistocracy above us. We've lost our way. The generations will see ridiculous rules and hypocritical leadership when they could have seen the wonder of life as a physician when we knew exactly what we were here to do. And were allowed to do it. We were a little disorganized, but our hearts were on fire. Maybe, just maybe, it's time for a reformation.

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    In Brief

    Fixing the Physician Shortage

    The Association of American Medical Colleges projects a shortage of 65,800 primary care physicians and more than 64,000 specialists by the end of the decade, according to their website. The problem will likely grow at the state level, too. A study by the Minnesota Hospital Association, released in July, found that a physician shortage is likely to emerge in Minnesota within the next decade.

    FierceHealthcare offered potential technological, legislative, and educational fixes. (

    Telemedicine is a growing option for rural health care facilities because it makes it easier to provide virtual health services in an environment where it's difficult to recruit and retain physicians. A 2013 Health Affairs study went so far as to say that electronic communication could eliminate the primary care shortage by implementing a partial pooling of patients and diverting as little as 20 percent of patient demand using health record-enabled electronic communication.

    A possible legal solution is to expand the authority of other medical professionals, like PAs and nurses. Kentucky passed legislation this year that gives nurse practitioners the authority to prescribe routine medications without supervision after completing a four-year collaboration with a physician.

    An educational fix suggests providing resources on education and training. President Obama asked Congress in February to pledge more than $5 billion in training resources to offset the shortage. The proposal would use the additional funds to train 13,000 primary care residents in the next decade and increase the National Health Service Corps from 8,900 to 15,000 primary care providers a year.

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