“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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