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“He jests at scars that never felt a wound”
-Romeo and Juliet

Barely had the last edition of Emergency Physicians Monthly reached mailboxes when I began to hear from everyone who took offense at the idea that our research needs to be reexamined. I heard from both my friends and my enemies, and at my age they all start to look alike. They are the faces you can recognize at emergency medicine cocktail parties, the usual collection of limousine liberals who feel they are entitled to research dollar and academic protected time. They are my contemporaries (give or take 10 years) and have declared that the aggrandized affluence spawned from the cultural revolution of the 60s is still alive. They take a circumspect view of people who “just” see patients and believe that there needs to be endless research dollars and expanded positions for the work averse. A commitment to one’s trade, living within one’s means professionally, and saving for the future have been declared passé in the bosom of “let the cost be damned” excess. This Belle Époque era is viewed as the manifest destiny of American medicine.

Now programmed to irrational expectations, professional self-indulgence and immediate gratification, there is little attempt to try and respect the growing abyss between the average American workers’ output and the cost of healthcare. The nemesis is more than just the dollars, it is a lack of shared sacrifice. The inordinate shift in the income of American workers has never been felt by physicians. Having been there for most of it, I can attest that emergency medicine does not have a history so much as a success story. I pen this piece in Michigan where the average auto worker makes 30% less than he did five years ago. But even in this great state, which has seen so much rust belt pain, the numinous physicians have felt no pain. Financial confrontation with forces that have made us a second rate economic power seem to escape most physicians who pretend that neoteric navel-gazing will allow the problem to solve itself. Well, just to let them know, it won’t.

The paragon of our virtue should be addressing the limited resource issue head on. Yet instead, we join in fueling the insatiable consumptive urges of the medical industrial complex. We are directed on all sides through embargo, discussions of cost, workforce outcomes, and genuine needs. Medicine has joined other so-called entitlements as the inselberg of nonexistent debate.

Thoreau got it right 150 years ago when he said, “Men have become the tools of their tools.” It begs the question: Is there an app for serious thought and debate? Now is the time for questions concerning our research agenda. Now we must move to that mental landscape from whose bourn no traveler returns – the public good. This is where emergency medicine started and where it should return.

There are slightly over 4,000 hospital-based EDs in the United States. Is this the right number? How do we know? What should be the current availability of such care for the American people? Workforce at all levels constitutes 80% to 85% of the cost of healthcare in the United States, and yet there isn’t one laboratory-style hospital producing real data on staffing. What is the current doctor-to-PA ratio? What should it be? What cases require physician supervision and which ones do not? Can techs be substituted for nurses in certain situations? All of these questions need the thoughtful input of a specialty that recognizes both our strengths and our limitations. And yet, we as a profession remain strangely mute on these issues.

If we want real ways to look at costs as well as reasonable patient outcomes, why aren’t we studying the effect of closing many of our rural hospitals and turning them into 24/7 urgent care centers with excellent transfer capability? We need to do more than make snide remarks about the “bad cases” sent in to our glorious centers from East Jesus, Nebraska; we need to make the system work better. If you really want explosive healthcare delivery research, the question of the role and future of urgent care centers needs to be seriously studied. We have no clear picture as to how many patients they are seeing or the severity of the illnesses, how well they are doing and what their true dollar and societal costs may be. Are these just burned-out emergency doctors trying to avoid working nights, or is this a viable mechanism for unloading overburdened urban emergency departments?

While we are at it, the education of post-graduate physicians by the federal government is a relatively recent invention, having been put into place with the passage of Medicare in 1964. This is still the burden of the American taxpayer and we need to justify our training costs as reasonable expenses. Between MD and DO programs we now have over 170 residencies serving our specialty. But given the recent growth in the usage of PAs and NPs, have we studied and justified the need for maintaining the current number of residency slots? Being a personal friend of the first person to ever have the words “emergency medicine” on their residency certificate – University of Cincinnati, 1972 – I think our meteoric rise was appropriate and filled an important societal need. But the future is unclear. As such, the shift in workforce needs our study and considered policy influence.

This problem is set to explode. When our 401(k)s became 201(k)s, more physicians sought to extend their careers. Our practice environment, which began with second career physicians, is now almost exclusively manned by primary residency-trained doctors, to whom the effect of the total number of providers is paramount.

The cruelest thing we could do to our young would be to overproduce and let the vicissitudes of the market take their toll. Knowledge is power in these discussions, and this is the kind of research we should be encouraging. It benefits the specialty, our residency graduates and – heaven forbid – the taxpaying citizens of the United States.

I am no medical Luddite. I invite no intellectual sabotage. This is not a call for the smashing of test tubes or the abandonment of chi-squared tests. But to anyone who believes we are going to solve our larger healthcare issues without addressing these more basic questions is whistling along to the beat of CPR being performed in room 4.

I propose we become the first specialty to be able to sit at the table with third-party payers, including the government, and be able to propose proper solutions based on real data and the real needs of the American people. To do less is beneath our dignity and insults those who, in 1968, brought us into this brave new world of emergency medicine.

“And ye shall know the truth, and the truth shall make you free.”
-John 8:32

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Comments   

# article on cmedr rosemary mitchell 2012-05-09 02:01
I rrecently read an article by Dr Greg Henry on CME and would like to refer to it on an address to the members of the Fiji College of General Practitioners in Fiji.Please can Dr Henry indicate his permission for me to use this article.
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# Friend (not Foe)David E. Wilcox, MD, FACEP 2012-05-09 06:55
Hear, hear, Greg! Well said; I agree completely. There are many vested interests (providers, manufacturers, payors, etc.) all trying to protect their piece of the medical pie, not the best interests of society at large. As Europe and the UK realized well over a decade ago, we in America need to begin making the hard decisions and answer the hard questions, i.e. just how much can society afford (the pocket is not infinitely deep; we cannot do everything for everyone all the time), and where do we get the biggest bang for our buck (comparative effectiveness; get rid of all higher cost alternatives that add no clinical benefit, but just line the pockets of providers or manufacturers at societal expense). While in America we decry "rationing" and "death panels", in Europe they call it "Choice", societal choice. Do we continue spending astronomical amounts on individuals, or do we spend that amount on numerous people with many more quality adjusted life years in front of them? We need to spend society's limited health care dollars more wisely; we can't continue indefinitely funding the long acknowledged "unsustainable" upward spiral of health care costs. It would be good if Emergency Medicine became a more rational beacon to lead the way, at least in our piece of the medical pie.
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# Lots of waste everywhereKevin Holcombe 2012-05-11 13:27
Well said Dr Henry! I have been muttering these thoughts to myself, but thank you for making the obvious more public! Similar analogy is the space program (and I know I'm going to offend some people here) - several years ago on NPR I listened to an interview with one of the NASA higher-ups, and the "higher-up" was never able to answer the repeated requests for examples of the "miraculous" medical advances made in space that have benefited the USA and/or the world!
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# More Questions Than Answers?Chris Carpenter 2012-05-20 05:56
Dr. Henry's essay contains many truths, but leaves me with more questions than answers.

1) Who is the "we" in the statement that "I propose we become the first specialty to be able to sit at the table with third-party payers, including the government, and be able to propose proper solutions based on real data..."? More importantly, who will select the "we" and how will I know that they represent the interests of my patients, practice, research, and community?

2) Beyond wishful thinking and a hopeful prayer, what is the role of the individual physician caring for patients every day with no interest in conducting research to shape this more pragmatic research framework?

3) What is the role of the new Office of Emergency Care Research within the NIH see (http://www.epmonthly.com/features/current-features/is-there-a-future-for-em-research/)

Thank you for another thought-provoki ng essay. More detailed contemplation about the specific roles of stakeholders and policy-makers will move this essay closer to actionable solutions.
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# authorGreg Henry 2012-05-22 07:59
My thanks to my friends for writing in support. Dave and Kevin made great points. But Chris Carpenter has really laid down some tough questions. Let me try to answer some of them. First is the one about who represents the royal "we". This is what the boaed of ACEP is all about. If all they are doing is fighting about the money they are doing very little to change the direction of the ship. I was president for awhile of the Emergency Medicine Foundation. This is where directed research should be done to guide health policy decisions. We have been captured and taken over by the exact people who don't do policy work for a living. More CPR research funded by the foundation never answers any big questions. The board needs to lay out questions to be answerd. I am more than happy to assist. Your second question about the role of the work-a-day doctor is on point.ACEP needs more working doctors to site on boards at the state and national levels to bring some common sense to the seats of power. At the day to day practice level there are things to do.Stop ordering usless tests. Let people who need to die,die.Don't run codes on dead people. Meet with your local nursing homes and get things straight. We would be sent to jail if we did to our dogs what we do to people! The recent release on the dangers and uselessness of prostate cancer screening should give us all hope that there is some hope for intelligent health care in this country. Lastly, I will believe the NIH when I see it. Another group of pin heads who have no idea how

to fit research into our financial constraints. Good luck getting people who have made their reputations doing mediocre research stop others from doing more mediocre research. This is the work averse supporting the work averse. Thanks to all for writing Greg
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# Research purposesResearcher 2012-05-22 10:22
How do we know research will benefit the patient or public health when there are competing interests?
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# Research agendaResearcher follow-up 2012-06-04 05:38
How should evidence based health practice shape the research agenda? How should a health policy advocate best utilize available EBM to discern direction for public health research?
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# authorGreg Henry 2012-06-05 09:23
In response to Researcher: We must as people of science agree that excellent research does have a placein improving care but this can not be debated outside the larger context of social responsibility and resource limitations. The OPALS trial from Canada is the excellent example of truley superb work which asked simple and has changed our thinking. The NEXUS trial on c-spine is the same. I would bet that thousands of people have been freed from the backboard without x-rays because of it's results. Why are the British so much better than the US at asking the right questions? If our projects are not going to save money and give better patient outcomes then we should not be funding it.The old days of loose money are gone. We need to stop the competing agendas of academic tract advancement done by weighing the publications. GLH
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