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What to D.O.

Emergency Medicine is Dying

Pescatore, Richard DO

doi: 10.1097/01.EEM.0000722380.38493.47
    FU1-2
    Figure:
    corporate influence, medicolegal
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    I've recently taken on a role in public health, and spend most of my days caught up in policy and procedure. I haven't left emergency medicine, and I return to the emergency department for a handful of shifts each month.

    At times it's rejuvenating to find myself back in the familiar chaos of the ED, but I hesitate sometimes because of the change I've seen in emergency medicine in my short time—a shift away from interventionalism, calculated risk, and calm confidence and a continuous move toward overconsultation, undertreatment, and liability-shifting.

    Emergency medicine is dying, and it's the ultimate irony that EPs will sit idly by as the specialty circles the drain, bradys down, and dies a terrible and dirty death by its own hand.

    Endlessly Innovative

    Fifty years ago, a handful of great men and women—titans—recognized the need for highly-trained, endlessly innovative, and fearless physicians to stand ready for anything that might breach the ED doors every minute of every day.

    EM has defined itself over those decades as much by tending to the critically ill and injured as by serving as the enduring safety net for the marginalized and disadvantaged. The ED has become the last shining light for Lady Liberty's huddled masses. We've been the golden door. We've held the lamp for the tempest-tossed, the tired, the poor.

    What's more, driven by the power of global connectivity and the cornucopia of medical education and information sharing, emergency medicine has trailblazed in medical education, asynchronous learning, and continuing education. Somehow, lightning struck twice. Another generation of titans came along.

    Outside Our Scope?

    But the tides have shifted. Through corporate influence, the unrelenting medicolegal specter, and an image problem that would daunt even the most accomplished PR firm, emergency medicine has forgotten the culture of compassion and ingenuity that brought us to where we are today.

    Rather than asking how we can help, loud voices insist on changing the narrative to “so what,” implying that some bar must be met to merit our services and expertise. We focus on and champion rare or invasive actions when the simplest tasks make the greatest difference. Emergency medicine cynics scoff at primary care interventions such as antihypertensives, antidepressants, smoking cessation, and fall prevention, declaring instead that such benign treatments are paradoxically outside of our scope and not our responsibility, as if the letters behind our names and the oaths we took have a limit beyond doing what's best within our skillset for the patient in front of us.

    The bar was long ago set as a stepping stool, not a barrier. To continue to restrict our knowledge base and interventions to life and limb threats is to ignore the greater half of our mandate—to stand ready for the wretched refuse, the tired, the poor.

    The patients suffer.

    The consultants suffer.

    The learners suffer.

    We all suffer.

    All because of a generation of effeteness, elitism, and abdication of responsibility. Too often I watch as we become the lampoon other specialties would make us out to be, calling for consults just to put a name on the chart or to offload some misperceived presence of medicolegal liability. We pawn off procedures and shift responsibility to all but ourselves, all secondary to what has become a pervasive fear of ownership, baked-in to training curricula and rife throughout our literature and conversation.

    Emergency medicine is dying. It needs resuscitation. It needs a refocus away from corporate ephemera, whether I can have snacks at my desk, and how much yoga it will take for me not to melt down after yet another shift where the specialty is denigrated or where I witness half-baked medical knowledge passed down to share liability, shift responsibility, abdicate accountability, and perpetuate a bastardized notion of what the emergency department means to our country's most in need.

    Emergency medicine is dying, and it's an enduring tragedy that we ensemble of resuscitationists, we merry band of doctors so enamored with our ability to stare death in the face and live to tell the tale, will stand by and watch until the monitor sounds its final tone.

    I haven't left emergency medicine, but emergency medicine is trying to leave me. With my shift to public health, I've shifted to a new emergency department. It's my enduring hope that I'll find that I've simply fallen victim to my own observation bias, and that I'll find the specialty alive, well, and ready for dispo.

    Dr. Pescatoreis the chief physician for the Delaware Division of Public Health and an emergency physician at Albert Einstein Health Network in Philadelphia. He is also the host with Ali Raja, MD, of the podcast EMN Live, which focuses on hot topics in emergency medicine:http://bit.ly/EMNLive. Follow him on Twitter@Rick_Pescatore, and read his past columns athttp://bit.ly/EMN-Pescatore.

    Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
    • likeafox411112:15:25 PMEM never should have been its own specialty but an FP fellowship.
    • mkosdoc7:26:56 PMGood move to public health. There are so many residencies now in EM that soon you will not find a good job or pay will be so low that it will not be worth it to work in this highly litigious field.
    • Gary Thompson, MD3:36:59 PM<p>Great comments, Dr. Pescatore. The profession has seen the writing on the wall for some time&#58; dysfunctional. You noted that &quot;EM has defined itself over those decades as much by tending to the critically ill and injured as by serving as the enduring safety net for the marginalized and disadvantaged.&quot; We have treated marginalized and disadvantaged patients as we would any patient—with compassion. And we don't compound their circumstance. Millions of laypersons in the USA, Canada, and Europe were taught the signs of breathing emergencies. Then they were told to deny rescue breaths and just give chest compressions. Laypersons eagerly follow orders. As always, we should be safe, kind, and first, do no harm.<br></p>
    • David Denton Davis, MD2:25:21 PM <p class="MsoNormal">Dr. Pescatore, Congratulations on your extremely cognitive and well written summary of the demise. Two days ago, I came across some token memories as I was packing; an engraved wooden plaque given in honor of my participation in creating the first board exam for your specialty and another for being a charter member. Next, I found book ends from that same organization thanking me for my leadership role as board of directors member from 1973 to 1976. I had placed these items in a box destined for disposal. Today, after reading your first paragraph thanking the founders, I felt a degree of pride and decided that care still exists buried beneath the garbage, and I reflected upon my own mission. My mission for the past 20 years has been to have our organization assume some of the physician responsibilities associated with the National Childhood Vaccine Injury Act of 1986. On our 50th anniversary in 2018, this organization finally acknowledged the existence of NCVIA and the Vaccine Adverse Event Reporting System (VAERS) but deliberately chose not to go any farther. </p>
    • ajmurn9:54:11 AM <p class="MsoNormal">Well, I half agree. I believe the specialty has changed significantly in the past 30 years. Some of it’s good; some of it is not so good. I absolutely disagree that emergency medicine should be synonymous with primary care. The emergency department also should not be the diagnostic center for the medical community, although I would recommend hospitals set up diagnostic centers to help primary care providers complete their tasks. The cry of “send them to the ED” is offensive. Perhaps you’ve never really paid your own bills before. As someone who used to work for a living in industry, I can assure you that a couple thousand dollars of an ED bill that did not need to happen is incredibly crippling. The ED cost is prohibitive with stat charges on labs, radiology, stat reads, etc. The job as the primary care provider should be primary care. If we identify something, it should be referred to primary care. The idea that we have to do some extensive workup looking for the most obtuse zebra is absurd. If the patient is stable, he belongs with the person who is going to follow him. If you treat these things in the ED without proper training or proper follow-up, the patients simply come back. Tell the guy with the shoulder pain sitting in the waiting room while you’re taking care of your recurrent hypertensive patient that he can wait with his heart attack. It happens. Sheer cost demands more intelligent use of resources. As far as a joint residency goes, if you want to work in the emergency department, do a residency. In other cases, if your residency did not suit you, then do a fellowship. Either way get the training and practice in that scope. I have worked in some of the busiest departments and some of the slowest departments in this country, and the problems are the same. And this is from a blue-collar guy who is an anti-elitist. As far as getting another consult on the chart to cover your butt, I would suggest that perhaps you need a different specialty. In the emergency dep,artment we hang on the edge all the time, and that’s what we are trained to do. Reach out to extend your envelope. Unfortunately, the medicolegal situation is unavoidable. Winning a malpractice suit doesn’t feel like winning. This situation is real, and must be accounted for at all times. I suspect that treating things that are out of our scope when it would take another day or a week to get to the proper physician is better for the patient and the system. It also sets us up to try to avoid the sharks. It certainly is better for the overall cost. To get these people into primary care, unfortunately, too many providers have forgotten about that, finding it easier to order another test instead of simply looking at the chart. I promise your bleeding pregnant patient’s blood type has not changed even after five or six tests. Twenty belly CTs? Really? Eventually, this could cause the system to collapse on finances alone. Or even worse lead to rationing of care. So, as wonderful as it would be to be everything to everybody, it is not only impractical, it is not wise.</p>
    • vecuronium8:44:10 PMSobering reflection of a once vibrant and exciting specialty that has become a veritable hot potato.
    • frankdugganmd11:50:11 PMVery thoughtful analysis of a deeply disturbing trend with some great comments below.
    • David Hoyer, MD3:44:29 PMWell said, Dr. Pescatore. Regarding antidepressants, it is well documented that, on average, about one in five emergency department patients is clinically depressed. If you are not screening for depression and initiating SSRIs (or at least referring), you are missing an opportunity to help patients.
    • degrandpre886215:26:20 AMExcellent observation, one I have noticed over my 20-year career. I sometimes think, &quot;Is it me who is not practicing good medicine by not consulting everyone and doing a CTA chest/abdomen/pelvis on all my patients?&quot; But then I am reminded by my patients and nursing colleagues it is not me. Their kind words and heartfelt thanks have gotten me back to work every day. I know we like to blame big corporations for our demise but having worked at both, with the past 14 years in a private group (I was president for many years), the private sector is just as bad or worse. We have turned on each other and become very selfish with our own ambition and self-preservation. I for one have lost my fight to try to fix it and do the right thing. I will continue to try to lead by example and not sacrifice my own moral compass but don't have the energy to try to change the current course. Hopefully, the younger generation will turn it around because what we do is so important and ultimately the patients are paying the price for our failures.
    • booth1980612:05:18 PMAccurate observation and prognosis. I am an emergency department PA-C of 15 years. Essentially, as a permanent resident, I have interacted with countless ED attendings as mentors, colleagues, and eventually friends. But I have to agree with this article. I cannot tell you how many times my attending has told me to consult surgery &quot;so we have someone else on the hook.&quot; Or fill in the blank for the consult, for the same reason. Emergency medicine seems to have become more about how to get as many of your colleagues in the medicolegal net with you than how to really own and care for the patient. For many of the same reasons the author expressed, I too have moved out of full-time ED practice and into academia. Medicine as a whole has shifted in an unhealthy direction. The hyper-fracturing of the body into so many subspecialties may eventually backfire on physicians. When everyone only takes care of a piece of the patient, who will take care of the whole patient? I think this avenue that physicians have set upon is leaving their profession vulnerable.
    • twiedman11:33:27 AMWhen I finished residency in 1976 and began a 40-year career in EM, life in the ED was fun and challenging as we learned on the job. It was rewarding, filled with the camaraderie of working with congenial staff, enabled by easy access to administration we knew by first names, spiced by the need to become business-like in managing contracts, and scary because of all that we did not know. I second Dr. Pescatore's view that much of that has changed with CYA, the elitism of ACEP/ABEM that prevented many of my most talented partners from gaining board certification, the reluctance of many consultants to respond appropriately to calls from the ED, the loss of contact with administrations behind their moats of ever-increasing numbers of midlevel suits, and the rapacious buying of contracts that inevitably led to the loss of pride of ownership for local emergency physicians. Now, many emergency physicians are simply employees of large corporations that have little feeling for their locale or needs, and they are constantly running scared of seriously-flawed patient satisfaction services. Job satisfaction is diminished, and job security is minimalized.
    • William Maliha, MD10:53:15 AMI am a retired former full-time faculty at an academic EM program. I also did government work and community emergency medicine. Throughout my career, I believed and advocated for EM to be a dual specialty with family medicine. Both treat the same spectrum of illness and both treat patients of all ages. FP has a long-term approach while EM serves in the acute care arena even as both see the same pathology with the exception of major trauma. A four-year residency would accomplish this and would enrich both specialties, both clinically and intellectually. Patients would be the better for it.