altInductive 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 emergency medicine.

“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 them.

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.

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