As I traveled from Prague to Stockholm I realized just how universal the issues in emergency medicine have become
Last month I was given the distinct honor of giving the opening address to the Swedish Society of Emergency Medicine as our specialty became officially recognized as a board certified entity in Sweden. The Swedes have watched with growing envy over the years as emergency medicine in America has gone from a rag-tag army of the restless and bold to one of the most sought after medical training programs in existence. Americans are always their own worst critics; we often forget to sit back and objectively view how far U.S. emergency medicine has come. This June we will matriculate over 2,000 first-year residents. This is a number which confounds even the Chinese. We sit at medical meetings as equals with all the other specialties. And at such meetings everyone is aware that many of the best and the brightest medical students are coming into the emergency medicine fold. Britain has pretty much been a partner in this endeavor from the beginning. Much of Europe is still following, but make no mistake about it. Just like the space race and rock ‘n roll, this is an American-led experience.
Sweden was just the final step on a trip which allowed me for the first time to visit countries which just nineteen years ago were closed to the West. It’s amazing how everybody’s problems are the same. Sitting at the Art Nouveau coffee houses in both Budapest and Prague and reading the papers (the Czechs are kind enough to print a summary in English), you could change the names and believe you were in the United States. Budapest doesn’t know what it’s going to do with its elderly and all programs are being cut back. They have decided to charge higher fees for the mineral baths that were the wonder of Europe in 1896 when the Hungarians celebrated their one-thousandth anniversary as a people. The baths were considered medical therapy and are run by the Department of Health. (Who knows how they’ll handle payment for chiropractors.) Programs are being slashed due to – you guessed it – the shift in the dependency ratio. Hungary, before the Second World War, had over 11 million people and has now fallen to about 9 million and is not stabilized yet. They are still recovering from both the Germans and the Communists. Both of these forces were uninvited and cast the same pall on childbearing from which they have not fully recovered. They are still crawling out from under the myths that rely on fraud to demonize opponents and stoke the fires of intolerance. There is an intellectual middle-aged malaise which still infests Eastern Europe; they don’t know what to do about societal programs which have been made, are expected and cannot be kept financially sound during these difficult times. Sound like anywhere you know?
We move on to Vienna where the schnitzel is unmatchable, the streets are spotless and humor is almost nonexistent. It’s strange. I stayed at the 39-room hotel behind the Cathedral where Mozart lived when he wrote “The Marriage Of Figaro.” I am not certain what it is about the Austrian/German mentality, but they follow directions well. Everything is meticulous, down to the letter. And yet, they’re having trouble with emergency department overcrowding. Change the names and the language of the paper and it could have been Cleveland. Proposals about charging for emergency visits, stopping nursing home transfers without authorization and reviewing drugs of marginal utility fill the ears and conversation. As in most European countries, the single largest expenditure is health care. And like it or not, it is the center of attention when things go wrong.
Before I move to Sweden, I must comment on Prague and the Czech Republic. The Hotel Paris was also kind enough to have an English summary of the daily papers. Headlines for three days in a row blasted: “Crisis In Emergency Care” with standard stories about hospitals closing to ambulance traffic. One day while we were there, every hospital in the city of Prague was on diversion. All our horror stories from previous decades were being played out again in the Czech Republic. The Mayor was on television expounding on the problem. The Legislature was meeting both night and day. Again, the scene could have been taking place in the United States, in the 1970’s or 80’s. Rules set up during the Soviet occupation about bed days for certain diseases are still in effect in Prague. Many feel grandma “deserves a rest in the hospital” and emergency patients waiting to be admitted should be damned. They don’t realize that there are too many grandmas and not enough working grandkids to go around. They have yet to make the fundamental changes which are necessary to keep the system moving smoothly. The Czechs, like the Austrians and the Hungarians, don’t recognize emergency medicine as a completely separate specialty as we do; so at least they can’t blame the people in the ED as the recognizable group that’s at fault. Disaster, rather than crisis, would be the ampler, more evocative term for what was going on in Prague. Having stated that, let me remind you that for the past ten years, ER has been the most popular TV show in all three countries.
Different countries, different systems, different methods of payments, yet the exact same problems exist. It should be reassuring to know that we are no worse off when it comes to problems of supply and distribution than most of the Western world. Every country I have mentioned has a shift in population that needs a shift in thinking. Governments are generally twenty years behind the population at large in both thought and action. The countries that are watching the Euro Zone fall apart economically are having a tough time borrowing money – medical modernization is not going to be first thing on their lists. The movement to an outpatient world will not be easy because so many people depend on so many government jobs. This is a shift which exasperates them every bit as much as it exasperates us. Limits in care and resources will come hard to all societies raised on the largesse of the young.
And finally, the Swedish experience. As with all such events, there are multiple layers of thought and intrigue and you always get down to the real conversations at dinner. One should never underestimate the effect of fine food and strong drink in the discovery process. The president and vice president of the Swedish Society hosted the dinner for my wife and I. We were joined by David Williams, past president of the British Association and current president of the European Society of Emergency Medicine; a true gentleman, scholar, as well as the best speaker in emergency medicine I have ever heard. It was, to say the least, a true honor to be invited.
The purpose of the dinner was quickly made clear as two young physicians who were about to lead the new era in Swedish emergency medicine began questioning us, the two old men who’d been through the process by helping birth the specialty in the U.S. and in Britain. Dr. Williams and I smiled with each question because every problem the Swedes are having were all-too familiar. “How do you get respect?” “No one takes us seriously.” “The anesthesiologists think they can do everything and the surgeons know they can do everything.” “What’s the secret to success of a specialty?” Our answers were essentially the same: “There is no quick fix, no short-cuts to acceptance. People (that includes doctors) gravitate towards people who can clearly state an issue, then solve the problem. We have now raised a generation of emergency doctors who were residents with the internists and the surgeons. They all know our trainees can do it as well if not better than any other specialty. Our people show up (which is 90 percent of success), work hard and keep the patient first in mind. If our Swedish colleagues do as we have done, they will grow in acceptance and respect. There are no secrets, just hard work.”
I was honest enough to advance the theory that there’s not always a happy ending. Man must know how to live with the tensions of victory and defeat, advance and retreat. There are no assurances of how the entire process will ultimately end. But just keep at it every day. We are still the one group of doctors who takes on every problem night and day without prerequisites. That has tremendous value in any and all societies. To quote Andrew Coyne: “A society that believes in nothing can offer no arguments ever against death. A culture that has lost faith in life cannot comprehend why it should be endured.” Emergency physicians have consistently protected and defended life and to do so is in the best traditions of medicine.