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.
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 atwww.nursingcenter.com, and Working Knights, Cats Don't Hike, and The Practice Test, all available atwww.booklocker.com, and of a blog, http://edwinleap.com/. Follow him on Twitter@edwinleap, and read his past columns athttp://bit.ly/EMN-Emergistan.