As our specialty matures, we must enter an open dialogue about career progression and the aging physician.     

“Laborare est orare”
-Horace/St. Benedict

This famous quote from Horace can loosely be translated as, “To work is to pray.” St. Benedict, in his grail-like quest for Western monasticism, used it to point out to his devotees the value of work. They were right; working is like praying. It is how we identify ourselves. It is, to a very great degree, who we are. The reasons for labor, apart from the obvious monetary compensations, are many: self-pride, self-worth, self-reliance. This is what humans are all about, and unless you take a Marxist view of the distribution of goods and services, we understand that individual work is the hallmark of the free and the strong. The problem with emergency medicine as a career choice, and its initial residency training, is that we refuse to admit that the nature of work must change with the health and age of each doctor.

Having been involved with ACEP and emergency medicine almost from its inception, I have seen the maturation of a specialty. At each stage of development we have had different dragons to slay. We lived through the, “You’ve got to be kidding. No one would do ER for a living,” phase. Next, we went through the land-on-the-beachhead residency-building phase. In the late 70s, we all got together and gave $150 apiece in order to form a board, which no one else recognized at the time.

Finally, we got recognition for our specialty from the American Board of Medical Specialties.
But time moves on. We are established, admired – even envied – by many of our colleagues in the broader house of medicine. We are slowly losing our defensiveness about being second-class medical citizens. But the new monster waits and is about to rear its ugly visage. First, we need to come to grips with the reality that our chosen profession is not dermatology. Wrestling drunks at 2 o’clock in the morning loses its appeal quickly, and the physical demands of the job can take their toll. Second, we have to be honest about the current economic crisis and the realities of retirement. You are not going to be able to retire at age 55 or 60. The deficit reduction commission said recently that we will need to be 69 to retire on Social Security in the future. Every major economist knows that this is a joke; the number will be closer to 72 if you expect eight years of support from your government near the end of life.

I propose that we start now with a frank discussion about the new demon in our midst: the maturation of the emergency medicine career. Let’s keep it simple. Not simple as in “no problem,” but in the way physicists use the term: profound simplicity. Not simple-mindedness, rather the simplicity to which scientific reductionism leads us. In training, very few residents are ever asked to picture their lives at age 50. The flawless harmony of a properly matured career should be in conformity with sublime reason. It should never come as a surprise to an emergency physician that they will need to change and refocus their career. Life should be a great thought, not an endless machine.

I have, over the years, worked with sophisticated emergency medicine groups to consider how to extend the work life of the physician. Everything from scribes to urgent care shifts to travel and industrial medicine have been debated. To begin with, shift lengths need to be shortened as we age if we are to be long-distance runners. Also, we need to seriously consider the transition from emergency medicine to administrative duties. No specialty prepares us for broad administrative responsibility in running the healthcare system like emergency medicine. After all, we make a broken, almost non-existent system work. We are so good at doing more and more with less and less that I expect to start seeing us do everything with nothing.  We need to consider and take action on these issues, at both the ACEP level and through our journals.

From the moment men and women enter the specialty, we need to start talking about what the specialty will look like for us down the road. Let’s carry on an open forum on the maturation dilemma. After all, put enough days together and you have an entire life. For emergency physicians, a long time may be two hours, not 20 years, but let’s talk about what the life can be . . . and how we can still be productive at age 72.

Every emergency doctor has had moments where they wonder what lies ahead, and what the end of their career will look like. But the only way to predict the future is to make it. And the only way to make it is to come out of the intellectual closet and admit we need to start realistically discussing all the directions the practice can take us. Many physicians in their mid-60s (hello) and 70s not only want to work, but need to work. Not just for the money, but for the thrill of being creative and productive. Shuffleboard is not the proper ending for a life which as been built on the thrill and joy of saving other people’s lives.

Remember the grand unification theory in physics? It combines the fundamental forces of the universe (strong, weak, electromagnetic) to posit symmetries that involve rotation in abstract space and time for more complex dimensions. It unites and finds a collective name for these forces, suggesting that they are, perhaps, manifestations of a single, underlying force. I propose that the emergency medicine career needs its own grand unification theory. We need to take the strong elements of our practice, such as training, systems management, firsthand knowledge of disease and a perspective of its societal implications and blend them into a unified theory of what a career should look like. We need to move towards raising our young with minds of infinite profundity and infinite simplicity. From all quarters – academic, private practice, government service – please join me in this dialogue. Write back. The only things we have to lose are our intellectual shackles.