Oh Henry

I’m home again for a short period of time. I’m back from the windy city, Carl Sandburg’s “City of the big shoulders,” where the 2008 ACEP Scientific Assembly took place. Having attended these events for the past 30 years, I can’t help but observe and reflect.

Having been in attendance at a council meeting I am reminded of how difficult and problematic and yet necessary democracy is. Certain issues just seem like they won’t go away. I commented to someone sitting next to me that when I die, I will know whether I’ve gone to heaven or hell. If I wake up and they’re debating the fellowship issue, I’m in hell. Fortunately, the council was able to come up with an excellent compromise solution, and let’s hope, for all of our sakes, that this issue has been put to bed. Most of what we do is fiddling while Rome burns. The real issues before us are how we are going to interact with other specialties and with a new administration and congress. For us to spend any more time arguing about letters at the ends of our names only strikes me as ridiculous.

Next, it is amazing to see how the exhibit floor has developed at the ACEP meeting. It is clearly the Broadway of emergency medicine. There is no emergency medicine meeting in the entire world that brings together this many emergency physicians who are the potential buyers of products and the purveyors of those products. It is probably impossible to buy a used car during the ACEP meeting because all of the used car salesmen are selling computer software products. The number of ideas that can come out of a computer is truly amazing. Does any of it actually result in better patient care? That remains to be seen. Does any piece of software move patients through the department faster? I’ve yet to see that proved. Have we really changed the lawsuit rate because of it? All of these questions still remain, and yet people continue to provide electronic alternatives to common sense and common decency.

A third idea, and thank god for it, is that the rage to merge in emergency medicine groups seems to have passed. I remember about ten years ago when the Scientific Assembly could be better described as the “American Association of Acquisition and Mergers in Emergency Medicine.” Someone actually found out that emergency medicine is a relatively low profit business no matter how you cut it. Doctors get paid real money and the amount of money left over is relatively small. It was a pleasure to see very little discussion about mergers, acquisitions and major financial structures at this meeting. The financial discussions were almost all interpersonal . . . and unhappy. Everyone’s 401k has become a 201k. The shift in thinking with regard to retirement and what other avenues one will take to earn a living tended to dominate any larger economic issues. The fact that emergency medicine has been unmasked as a low profit operation has allowed people to move on to other forums of discussion.

The coming together of the best and the brightest in emergency medicine each year directs the policy of how we will interact with the rest of the house of medicine and our largest payer, the federal government. As we await a new congress and a new president, one should never forget the fact that the primary role of ACEP is advocacy for our members. It was very clear that those doing the deep thinking on these issues have used the PAC dollars to gain access to people who will be looking at the health care crisis. The largest issues are not going to be those that are publicly debated, but those that are fought out privately. Those issues which are debated at the RUC committee (where the specialties go to decide what each one is going to be paid by the federal government) will be the new battleground. What is our worth compared to a dermatologist? What is our value compared with a neurologist? As the number of elderly increases and as the complexity of medicine goes forward, how we divide those dollars internally will determine where the best and the brightest of the students will gravitate for their residencies. 

Lastly, having spoken at the national meeting for the past 30 years, it is an absolute pleasure to see the shift in the faculty. I remember a time when half of the faculty came from outside of emergency medicine because we did not have the internal expertise to teach certain subjects. Subjects like cardiology, radiology and neurology were dominated by the specialists in other fields. This is no longer the case. Just to hear the quality of the speakers and the intelligence with which they approach the problems which we see in the emergency department helps us understand that it does matter what your frame of reference is when you are reviewing a problem. Emergency physicians see things raw and uncensored. It is really impossible for a neurosurgeon to speak about head injury evaluation in the ED. Quite frankly, he doesn’t do it! We do. The need to involve “specialists” is the real discussion, and I believe we are now a mature specialty which has a  grasp on its own field of expertise and limitations. It is an absolute reassurance that the profession as a whole is on the right track.

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