Inductive reasoning begins with observation and moves with variable
speed to generalized theory. Deductive reasoning moves the other way:
theory, hypothesis, observation and finally confirmation. But when you
are dealing with risk management issues you need to do both
simultaneously or you can be caught by the tsunami of thought and blown
out with the tide of history.
Our mortality is both certain and universal. We are born, live and die,
pretty much following the path of maturation, procreation and
disintegration as homo sapiens have done for the past 175,000 years.
It is a moral imperative that EPs become philosophers, asking the critical questions of why we do what we do. In his 1981 magnum opus After Virtue, Alasdair MacIntyre – who may be
our greatest living philosopher – challenges us to look for a new
paradigm to examine our life’s work and accomplishments.
To reprise anything, one first has to conclude that it made some impact
the first time. Following the entr’acte, you expect only the mellifluous
strains that carry the strong feelings of the first act. To this end, I
want to acknowledge all of you who have written about the last column
which dealt with the natural maturation continuum of a career in
“Laborare est orare”-Horace/St. Benedict. This famous quote from Horace can loosely be translated as, “To
work is to pray.” St. Benedict, in his grail-like quest for Western
monasticism, used it to point out to his devotees the value of work.
To think that ethnic prejudices are the only prejudices we
carry around is a huge mistake; we have all kinds of forces that push
the way we believe and act every single day. The key to being an
emergency physician is understanding your own prejudices and controlling
This year, on the exhibit floor, there were at least four booths
advertising scribe systems. I don’t understand why there weren’t 14. As
there is going to be more pressure on medicine to produce more patient
care for less money, the scribe is the obvious way to go.
The principle issue in this country today, with regard to medicine, is
not any particular form of research. It is not any particular operation.
It is what are we going to supply to elderly people where there are
limited resources and a shrinking base of people to pay the bills. This
is more than symbolic. It is a day-to-day problem which no one seems
able to deal with in any realistic way. And no one sees this dilemma
like emergency physicians.
Suffering is optional. Unfortunately for some of our patients, it’s at
our option and not theirs. As I look back and am confronted by some of
the most difficult patients that I ever cared for, it was the suffering
that was the problem.
As I sit, penning the cases to be discussed for the Mills Lecture which
will be given at the ACEP Scientific Assembly in Las Vegas, I am struck
by a thought: the largest, most-needed element of health care reform was
never discussed in the recent debate. This is the dilemma of what we do
as death approaches.