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Life in Emergistan

Life in Emergistan

The Everything Specialty Not Everyone Can Do

Leap, Edwin MD

doi: 10.1097/01.EEM.0000719100.09139.14
    emergency medicine

    We practice the specialty of emergency medicine. It's an odd thing to describe our body of knowledge, our skill set, as a specialty. We spend our careers on the border between specialist and generalist. Certainly, we have some unique skills, chief among them resuscitation of the critically ill.

    Just beneath those, however, are negotiating with drunk people, advocating for those on the margins of society, removing odd but non-life-threatening foreign bodies, cajoling other physicians to do our will via Jedi mind trick, sedating the agitated, managing long-neglected diabetes and hypertension, reassuring the parents of well children, managing multiple phone calls for transfers, and untold other things we do on a daily, weekly, yearly, career-long basis. It's a specialty, but it's a broad one.

    The exciting parts draw us into residencies and keep many in the hallowed halls of academia where the most cutting-edge therapies, research, and technologies make it seem more like the flier they picked up when they were choosing a career path.

    At some point, most of us begin to see that the shiny is juxtaposed against the burnished and dull. That is not to say those things aren't absolutely important. They just aren't as exciting. This is good. One can only bear so much excitement. A night shift where I sleep is exciting to me.

    I have begun to wonder more and more lately, however, about what it means to have our specialty. I can remember when I would have a very sick patient in the emergency department and would call another person who was, indeed, a specialist, perhaps a surgeon or cardiologist. And that person would come to the department to see the scary thing called a patient.

    Specialists v. EPs

    Frequently, I called them because I wasn't sure what to do. Almost as commonly, they were as bumfuzzled as I was. “I don't know. I'll admit him, and we'll see,” they would say. I remember the time I called an ophthalmologist because an older man appeared to have a spontaneous globe rupture.

    “I think I see his lens outside his eye,” I said.

    “Well, that makes no sense. I'll come in to see him.”

    He walked into the room and out. “Ed, I think that's his lens!”


    It was good. That was what specialists did. They put their hands on the abdomens of those with abdominal pain. They looked at fractures and reduced them. They listened to the breath sounds of children. Our job was largely to identify the fact that a problem existed and make sure it didn't kill anyone. Theirs was to continue definitive care.

    Outside the world of academia, and probably inside it, that has changed. And never more so than after 5 p.m. and on weekends or holidays when we suddenly become trained in every specialty known to man. I have called a cardiologist who was in-house about complex arrhythmias and a cardiac arrest with STEMI, and he barely registered any interest. And he certainly wasn't in a hurry to add his expertise to what I was doing.

    Call a surgeon? You had better have the CT report in hand or at least have the scan ready for them to review. The internist who is a hospitalist? No matter how sick the DKA, how complicated the respiratory failure, they will be managed by the EP who is the acting intensivist until every last lab and every unnecessary scan is completed. (Often enough to be followed by the assertion that they have to be transferred or are too sick for the ICU.) That is to say we are the hospitalists until the hospitalist is comfortable enough with the data to assume the job.

    Protecting EM

    It gets worse. In these days of the NP and PA, the idea of a specialty is blurred even further. When I transfer a patient from an outlying hospital, more often than not I speak to the NP on call for the cardiologist, the PA on call for orthopedics or trauma. When I admit to the hospitalist, it's an NP hospitalist. The specialty, the thing it took all those years of training and on-call nights to achieve? It's so specialized that it can be done by someone with a fraction of the training of a physician.

    There are particular dangers here as resident physicians have their work done by APPs and, for instance, don't round on their own surgical patients or change lines on their own ICU patients. Without careful attention, the things that make up a specialty will become irrelevant, and ultimately, so will the idea of specialization altogether.

    Oddly enough, we physicians hold on to the idea of specialty. I cannot simply say, “I'm going to go work as an interventional radiologist” or “I think I'll be a pediatrician.” Hospitals would consider this laughable, and doubtless so would specialists. “Why, that's crazy. You're an emergency physician! You have to go to residency again to do that!”

    I would counter, and we all should counter, that we're expected to do their jobs on nights, weekends, and holidays. And all day, all night, all around the country, nonphysicians do their jobs and will continue to do so more and more unless we reclaim the idea that a specialty represents a unique body of knowledge and is the domain of those trained in it.

    I'm an emergency medicine specialist. I'm very proud of that. As time goes by, however, I wonder just what that means. I urge everyone to consider the same question before we wake up one day and it means nothing.

    Dr. Leappractices emergency medicine in rural South Carolina, is a member of the board of directors for the South Carolina College of Emergency Physicians and an op-ed columnist for the Greenville News. He is also the author of four books, Life in Emergistan, available, and Working Knights, Cats Don't Hike, and The Practice Test, all available, and of a blog, Follow him on Twitter@edwinleap, and read his past columns at

    Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
    • wrigh209t7:09:33 AMI couldn’t agree more with this article. I graduated from residency five years ago and had my concerns then. I think the bigger question now is what do we do? As physicians, we need to come together before it’s too late. We need to take action or this may not be a job I work until I’m even 55 years old. We all see the writing on the wall, but will enough doctors take the time to stand up against it?
    • wlmulchin3:22:35 PMVery nicely written. Medicine has changed so much and not necessarily for the better.
    • mdbryant199810:08:02 AM Unfortunately, we have a failed specialty. Not that we don't have some great people doing some great things. After years of proving the value of an EM residency trained physician, we have been sold out. EM is now more about following the protocol and meeting the metric. I was asked two questions when I started my first position&#58; Are you good with procedures, and can you clear that waiting room? Now, as long as the patient satisfaction scores are high and the protocol was followed, your patient may be dead, but no one cares. <br><br>Actually, the list of things we have to remember, that have nothing to do with patient care, is so long, it is impossible to remember all of them. We are set up for failure. Don't ask why; just comply. Also, we evidently did not learn from anesthesia and are flooding in new residents to the point where some are having trouble finding a job. CMGs are now conglomerated so that in my major metropolitan area, there are two. <br><br>As individuals we are voiceless, and if you speak up too loud, you will not be invited back for shifts next month. There are five other docs waiting for your position. Now that we are employees, admin has us under their thumb. CMGs and independent contractor status was bad enough, but now we just answer to the head of the service line. It does not really matter, after all, we are no longer physicians. We are now just providers. <br><br><div>We have discussed the encroachment of mid-levels for years. Well, it is here. At my part-time hospital, I have been officially replaced by a midlevel for cost reasons. An entire physician shift was axed and replaced with someone who costs less. At this point, it is not unrealistic to think that in five years, the ED will be staffed by NP/PAs with a paramedic for airways. Of course, there will be one physician to sign charts and take the fall when something bad happens.&#160;As long as the midlevel follows the protocol and calls the specialist midlevel in a timely fashion, bad outcomes can be glossed over. Someone will write up a bad journal article that &quot;proves&quot; that outcomes are &quot;similar.&quot; But, hey, we are all in this together. In short, we are no longer considered special, either as EM or physicians in general. Everyone thinks they can do our job&#58; &quot;I mean how hard can it be. You just call someone to handle everything.&quot; Right.</div><div><br></div><div>A<span>nd i<span>f you complain too loud or visibly about the direction of our specialty, you will be labeled as disgruntled and burned out. Then you will be referred for mandatory Provider Wellness Training. Perhaps masks are useful for covering my facial expressions.</span></span><br></div>
    • mlewittmd1:33:59 PMAs usual, Dr. Leap is on the mark and demonstrates why his column is a monthly go-to for so many emergency physicians and others. I always found amusement that at 3 am on a weekend I could do anything needed for a patient, but at 3 pm on a weekday for a patient with good insurance I needed someone else to take care of the patient. EM has always been the first critical hour of every specialty; the time has been extended by several hours. Doctors with a generally superficial understanding, at best, of pathophysiology and relying on inside-the-box experiential thinking don’t get this, as too often the Dunning-Kruger hubris effect takes over.