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.
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.