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I have recently returned from my annual trip to the ACEP Scientific Assembly. It’s good to remember that this is the largest gathering of emergency physicians in the world. Even the Chinese don’t have a show this big. There is a circus-like atmosphere to the exhibit hall floor, and as I walked in, it actually appeared as a carnival midway. They were clearly only one malignant dwarf clown short of a circus. Fortunately, I showed up in time.

What many emergency physicians don’t realize is that before the floor opens, before all the hucksters and tricksters arrive with their popcorn and pens, ready to assault you with their non-improved products, there was an important meeting of the ACEP Council. This meeting brings together some 350 people to serve as the governmental forum for the running of ACEP. Over the years this council has grown as we have added representatives from virtually every segment of the emergency medicine community. All the various groups of interest within the College come to have their grievances heard. The ACEP Council is an event which, in my mind, every year calls into the question and then reaffirms completely the democratic process. You only need two members of the organization to sign a resolution, to have it brought forth before the Council and discussed. Churchill once commented that there were two things people should never watch being made: law and sausage. He was right on both counts. Good intentions don’t necessarily make good resolutions. The resolution process is the way that the great intellectually naïve and unwashed in emergency medicine can get a message to the Board of Directors. It’s how we let off steam.     

In some cases we spend endless hours waxing eloquent on almost nothing. The late, great Dr. George Podgorny (sit tibbi terra levis) an early president of ACEP, had an interesting view of the Council situation. George was born an Iranian and he speaks English in a most interesting style – the use of articles didn’t bother him very much. Having watched the Council go through the process of debating the wisdom of nuclear weapons some years back, George looked at me and said: “Council reinvent wheel. That okay. Because Council never see wheel before.” George was right. Sometimes we have an overinflated view of what our votes actually mean. I can’t remember any Secretary of Defense ever consulting the Board of Directors of ACEP on any issue of consequence.

But the Council can be how we take a stand on truly important world issues – even if no one else in the world is listening. We do it because our own Board of Directors is certainly listening. This is a way of passing direction to our leadership as to how we want the organization run. It’s not about the endless debates which go on about past and present participles. It’s merely a way of saying to the 12 people who run this organization on a day-to-day basis: “This is where I want my money spent. This is where I want you spending your time. This is what we need to do at this point in our history.”

During the next two columns, I intend to look at some of these resolutions because they do show underlying pressures and currents of thought in emergency medicine at this point in time. Just remember this: No resolution comes without baggage. They all carry hidden messages and agendas. The reason that certain resolutions are brought forward are out of distrust, fear and great concern about the future of the profession.

This year, as in all years, we divide the resolutions up into groups. There were those resolutions which just got tossed with resounding defeat, such as the one promoting (again) the legalization and taxation of marijuana. Message sent: it’s not our business. Multiple resolutions came and went with a little support from the Council members, typically because there was simply a lack of passion or understanding on the topic.

Then come the resolutions for commendation and in memoriam. All of the people so recognized were deserving but I must pick out one for special comment. Resolution 4 was in memoriam of Ronald L. Krome, MD, FACEP. For those of you who don’t know Dr. Krome, you missed one of the great experiences of your life. He was a fully trained surgeon who understood that the emergency department was going to become the central hub of clinical decision making. He paid a serious price for standing on the side of emergency medicine. He was made an outcast, a pariah, in the surgical world. But he carried on, helped form the residencies, the boards, and was instrumental, along with Dr. Tintinalli, in EM’s first major textbook. He was a character. He was fun. He was irascible. He was a curmudgeon. He was important in my career in that he was the man who in 1976 had me first come to the Detroit Receiving Hospital Emergency Residency to give talks on neuro emergencies. In 1980, he invited me to speak at the Scientific Assembly and 34 years later I’m still making presentations. Thanks, Ron. You are one of those people who truly affected and directed my career. God love you. If I may take some poetic license, let me combine two Shakespeare phrases to summarize Dr. Krome:

“When beggars die, there are no comets seen; the heavens themselves blaze forth the death of princes. So goodnight sweet prince and may flights of angels sing thee to thy rest.”

The Council took on some serious issues which required much thought. As readers of this column will attest, I have an interest in end-of-life care and the ridiculous things we have been doing in this country by beating the “almost already dead.” Well, this year Resolution 21 went to the Board, stating, “Resolved, that ACEP work with other relevant stakeholders to engage in a national conversation and make recommendations on end-of-life issues.”

Let’s get this straight. The biggest single problem in healthcare in America is what we spend on people in the last 90 days of their life. The biggest difference between us and the Canadians and the Brits and the Singaporese is not the treating of broken arms, cut legs, ruptured spleens or appendicitis. It is very clear where our money is being spent. Somebody’s got to talk about it. This is an area fraught with fear. Those who spoke against the resolution with some intensity said: “If we take this issue on, we could be painted as the doctors of death!” Bottom line is: If we don’t stand for something, we stand for nothing. We believe this or we don’t. The country is financially going to hell in a hand basket and emergency medicine should be at the center of these difficult decisions. Bravo to the Council for sending this on to the Board. Now let’s see the Board have the courage to implement something, do something, appear somewhere, talk to somebody about this issue because it’s not going to go away. The last time I checked, the number of gray hairs, of which I am a proud member, is growing, not shrinking. We need to act on this and this will be a bellwether test of our Board.

Resolution 24 stated that ACEP ought to “continue efforts at the direction of the ACEP Board of Directors to promulgate the value and role of emergency medicine.” This is overstatement of the obvious. We’ve been talking about this for 30 years. Our real role is not cut fingers, it’s not broken noses; it’s managing the healthcare system. It’s whether we put people into the hospital or treat them as outpatients. It’s coordination of healthcare in America. What we are seeing is a total shift in ideology. The vast majority of us when we entered medicine, viewed the hospital as the center of medical care. In the future, hospitals will be some operating rooms, intensive care units, observation units and emergency departments. The most dangerous square footage in the entire community are hospitals where we grow germs we do not know how to treat.

Emergency medicine’s role will only increase and this needs to be made clear. I again applaud this resolution, though it is a statement of the obvious. Every place that’s tried to “reduce emergency department use” has not saved any money. If the goal is: “excellence of care at the lowest possible cost,” we need to do that, plan that, run that through well-run emergency departments. It’s the only way to go.

Resolution 27 resolved that, “ACEP advocate for appropriate, adequate funding for rigorous research on firearm injury prevention. And be it further resolved that ACEP join the American Medical Association and other medical societies with similar resolutions to work together toward achieving this common cause.”

This is what I call pinhead liberal babbling. Someone has asked ACEP to study firearm injury. Well, the last time I checked, if you stand in front of a firearm, you get an injury. Exactly what they want us to study, I’m not certain. Exactly what they want done, I don’t know. The Board will take this, look and see what the AMA has as policy and probably nothing will happen. This is a voice crying in the wilderness because no one knows what to do with the problem. These types of resolutions come every year, whether it’s banning nuclear weapons or advocating for free food. It’s another way of trying to expand the role of emergency medicine in a place where our opinions actually are not sought.

Resolution 28 supported the “Decriminalization of Behavioral Issues.” What does that mean exactly? “Resolved, ACEP study the emerging alternatives to incarceration for individuals with substance dependence disorders and mental health problems in the United States. And be it further resolved that ACEP devise ways to support appropriate delivery of mental health, psychiatric care and substance dependence disorder treatment options as alternatives to incarceration.”

I can go with this. Everybody in emergency medicine knows that in many ways expanded mental health services are needed. Exactly what ACEP has to contribute to decriminalization of drugs is difficult to know. Again, this is an area where it may be a good idea, but what ACEP should be doing with it’s money towards resolution of this problem is to me difficult to understand. This is motherhood and apple pie – but what if on closer inspection the pie has worms and mother has gonorrhea?

Resolution 30 is an interesting commentary on our times, and suggests a fear that is abroad in the land. “Resolved, that ACEP affirm that a physician is an individual who has received a doctor of medicine or a doctor of osteopathic medicine degree or an equivalent degree following successful completion of a proscribed course of study from a School of Medicine or Osteopathic Medicine. And be it further resolved, that ACEP require anyone in a hospital environment who has direct contact with patients who presents himself or herself to a patient as a doctor and who is not a physician according to the definition above must specifically and simultaneously declare themselves a “non-physician” and define the nature of their doctorate degree.”

What’s happening here? I’ll tell you very simply. Physician Assistants are now getting PhDs. Should they be called “doctor” in the emergency department? Pharmacists are now getting PhDs in pharmacy. Should they be called doctor? This is a fear-based resolution. Physicians are afraid of losing their prestige and control. I understand the nature of this, but I think we may be fighting the wrong battle at the wrong time. The AMA has a very clear policy on this which states that physicians are physicians, period. But the battle will be fought at the local level since there is so little clarity on the supervision of PAs and NPs. This is a problem which will not go away until we take on the larger issue: Who is really in charge of the care of the patient? I have never seen a lawsuit where the “healthcare team” was sued. The doctor is sued. It’s the person who made the decision. We’ve waded so far into a “team” concept that we’ve forgotten that somebody is in charge and does bear liability and responsibility.

This issue – as evidenced by those who promulgated the resolution and became the most emotionally involved – rests most heavily on young physicians. The old physicians are going. They’re waning. But young physicians are concerned about their credibility, their authority, their responsibility in the department. I understand the basis of their concern, and the reasoning for this resolution. The AMA has dealt with this to a point. The fact that ACEP is again bringing it up only indicates how significant, how much fear still remains.

Before completing this column, I must make comment on one resolution out of order. Resolution 12 resolved that “the College Manual be amended by substitutions of the procedures for addressing charges of ethical violation and other misconduct.” It is very clear that the masses want action on the expert witness issue. Having probably reviewed twice the number of medical malpractice cases over the last 38 years as anyone else in the profession, I couldn’t be more in agreement. The garbage and junk science that can come out of the mouths of people who have “MD, FACEP” after their names is embarrassing. It is astounding and shameful what people will do for money.

The College does have to act in a straightforward and public manner to deal with unethical expert testimony. The membership wants action. It does not want physicians – particularly members of the college – spouting scientific untruths on the stand. If we are going to maintain a true profession, those people who besmirch, belittle and stain the profession need to be “silently neutralized with extreme prejudice.”

Iustitia omnibus

 

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