What a crash course in the Middle Ages can teach us about the past and future of emergency medicine
There is no universal definition of a weed. Look it up. It’s really that plant that we don’t want growing in our garden; a subjective point of view in which personal taste trumps botanical knowledge. But just as the quintessential garden elements are a matter of opinion, so are the important events of our history. Time is the only dimension we are all forced to march along with at exactly the same rate, and it allows us to look back at events and have perspective.
In retrospect, people and events do look different. But history should never pretend to tell us what our predecessors should have done according to our current standards. We should not project our moral turpitudes upon other generations. Remember the warning Napoleon gave us when he said: “History is a series of lies which men have agreed upon.”
In this diatribe, I’ll try and give some thoughts on the events – and non-events – that brought us to where we are at this point in emergency medicine.
The world as we know it was shaped over the thousand-year period we call the Middle Ages. It was the prelude to the modern era, but no one knew that at the time. Who knew that the single most important event to shape the Middle Ages might be the freezing of the Rhine River in 406 AD, which allowed the people of Germania to cross, marking the beginning of the end of the Roman Empire.
In the same way, emergency medicine was set into motion by forces we did not understand at the time. We look back to September 1, 1939, when the Germans (no longer the Germanians) invaded Poland to start the Second World War. Things would never be the same in medicine. The US transformed from a relatively lackadaisical industrial/agrarian society to one in which science and high technology dominated.
We became the most mobile society in history; no longer would the family doctor suffice. These moves required the need for hospitals to take care of transient populations and those without other doctors. And advances in science required concentration of finances and materials. The feeling in the country was: If we can explode an atomic bomb, we can treat cancer, diagnose appendicitis, and save people from car wrecks.
But the more important transformation of this era was specialization. In the 1930s, between 75-80% of all graduating physicians went into general practice. By 1968 (ACEP’s founding year) that number had dropped to about 15 percent.
Most hospital EDs were covered by staff physicians who drove in from home or came down from the operating room to see the acutely ill. It truly was an emergency “room” in the singular. But this wasn’t up to par with the country’s changing standards, so hospitals started to change in the late 50s. Some doctors began physically stationing themselves in the ER, to receive and evaluate cases. The hospital was in the position to force physicians from all specialties to “take their turn” in the ER (God help you if you were having an asthma attack when an OBGYN was staffing the ER).
Speaking of specialization, we return to the Middle Ages, to an event I would say that only history scholars and weird history buffs such as myself know about: The Battle of Lechfeld. While some of you may have a passing knowledge of the Battle of Hastings and the Magna Carta, little time is spent on this battle - which changed the entire history of Europe. In 955 A.D. the fluid borders of the Holy Roman Empire became clearly defined with this German (again!) attack. The Battle of Lechfeld was the first to feature knights on horseback as the key offensive element. Why? Because the knight’s saddle had been married with the stirrup,so great knights were not easily knocked from their steeds. There is an entire stirrup theory which historians debate, but there’s no question that it changed the way we lived. It forced specialization once again. The Medieval world subsequently divided into three fundamental groups: those who worked (peasants and artisans), those who fought (specialized armored knights) and the clergy who prayed. Feudal society as we know it rested on these three elements for the following 600 years until a new innovation, the long bow, changed history again at the Battle of Agincourt.
Emergency medicine had a similar experience. By the mid 1960s the Alexandria Plan was in full force: Doctors across the country in small, isolated groups began giving up their family practices to work full time in what we now call “emergency departments.” A fundamental change in perspective and education then had to take place. New warriors emerged. With David Boyd’s paper on trauma as the forgotten disease and every American watching Vietnam battle footage on TV each night, the need for rapid transport and knowledgeable evaluation became clear. Both the tide of history and the U.S. population were on the move and there would be no turning back.
In 1968, our own Magna Carta was signed. People from the group in Arlington, Virginia met with John Wiegenstein’s Michigan contingent, along with a few other assorted soon-to-be emergency physicians from around the country and a new concept was born. There were still no residencies, no textbooks, no examinations and no board certification. But the idea for a new specialty was alive, and there’s no stopping an idea whose time has come.
Returning back to the Magna Carta, it’s worth noting that ACEP’s founders in many ways did a much better job than did King John. If you haven’t read the Magna Carta, you should – once - and never again. Its 63 articles include everything from how big whiskey barrels should be to the problem with fish traps on the Thames River and what the punishment should be for the theft of firewood. But articles 38, 39 and 40, however, laid the foundation for individual rights against arbitrary despotism - a concept that has endured.
The Charter of ACEP likewise established a concept. It saw a need and presented a solution. In both cases, these documents were drafted by men of vision who saw changes in the world, and acted. Ironically, King John got the Magna Carta annulled three months later by the Pope. To the vast majority of English society, the Magna Carta was a non-event, yet all of us study it carefully in our formative education. Similarly, last year half the population of the United States visited an emergency department or urgent care center. And yet until the television series “ER” debuted, nobody really knew anything about us or who we were. To the people of this country, the founding of ACEP should never be considered a non-event.
Comparisons between the development of humanities during the Middle Ages and the blossoming of emergency medicine could go on ad infinitum, but I’ll close with one currently popular illustration of moves toward modernity.
In a recent book called The Swerve: How The World Became Modern, author Stephen Greenblatt posits that the discovery of a forgotten text by Lucretius freed man from the yoke of religious belief and allowed modernity to commence. The work is captivating, exciting, logical and mostly wrong; no one can be said to have freed the human spirit. But while Greenblatt errs with this claim, he’s mostly right when he argues that looking back is the only way we can move forward.
With the formulation of emergency medicine as a residency-based, board-certified specialty developed to solve health care problems, we moved on. Whether we have reached the zenith of that movement is debatable. You will see people defending the status quo, the way we train, the way we staff emergency departments, the way we provide education as “the way it should be.” And yet our forbearers were the ones who broke with tradition and changed the way things were. Change goes on. And those who would like to put up walls and stop further progress beware. If we are to be true to our founding fathers we must be looking at new ways to deliver care, which are both better and cheaper.
When Gutenberg invented movable type, some thought it should only be used to put out copies of the Bible. Angry mobs gathered (think Boris Karloff movies) to destroy the machine as a product of the devil. The lesson for us today is to avoid insular thinking. It’s impossible for us to say today what will be viewed by our descendants as the true events which shaped health care. Will they view the universal training in ultrasound as emergency medicine’s Holy Grail, or more of a side campaign? Will they see uncontrolled spending as the grave marker on a once great society? Which are the weeds and which are the flowers?
I am all out of crystal balls, and the ones that I do have don’t work that well. But Greenblatt is right: small finds and advances still set in motion collisions of history. We must be looking down the road and not dwell on the glories of our recent past. I take umbrage with those who see that we have reached an absolute in the provision of care. Methods will change. Motives to provide excellent care should not.
Hominen unius libri timeo
I fear the man of one book
-St. Thomas Aquinas