- Email: [email protected]
Dr. Nesbitt replies
c°rresp°ndence 1
I
Two P hysiclans, having begun thetr careers in small town a n d m o v e d to practtcing e m e r g e n c y ~nedwtne ~n high volume emergency departments, compare ~ews on emergency medtctne as d~stinct from faintly praclttce. In the opinion of William R. Nesbttt, MD, the main ~fference between hts background and that of Kevin M. o'Keeffe, MD is that 0 Keeffe s "has tts advantages since tts contemporary and not easdy confused wtth the older mage of general practice and conditions as they existed efore there was a Board of F a m E y Practice or an American ~ollege of Emergency Physicians."
~eneral practtce
i
PHILOSOPHICAL DIFFERENCE ITo the Editor." Back in y o u r M a r c h / A p r i l 1974 i s s u e you h a d a n mergency F o r u m article, " E m e r g e n c y Medicine and F a m y Practice" by W i l l i a m Nesbitt, MD. Upon r e a d i n g it, as r Nesbitt suspected, I did not receive most of t h e coments with e n t h u s i a s m and in fact would seriously d~saee with some of his s t a t e m e n t s . While I feel that, as Dr. N e s b i t t says, t h e r e is some 'common g r o u n d to f a m i l y p r a c t i c e a n d e m e r g e n c y !me&cine, I would not allocate the same percentage he has. iM0re i m p o r t a n t l y , I feel t h e r e is a basic philosophical or ipersonality d i f f e r e n c e b e t w e e n f a m i l y p r a c t i c e a n d :emergency medicine as well as the considerable a m o u n t of distract bodies of knowledge. I also support t h e g r e a t need for a steady supply of f a m i l y practitioners for this nation. W h i l e I a m a d a m a n t in t h e essential differences b e t w e e n e m e r g e n c y medicine a n d family practice, t h e y m u s t interface and recognize each ~0thers due role I do not t h i n k it is u n i n t e n t i o n a l or to the discredit of e m e r g e n c y medicine to "foster the philosophy 0ffragmented, episodic, crises oriented care," nor is it to the "detriment of the p a t i e n t . " I recognize the ideal of comprehensive a n d p r e v e n t i v e c a r e b u t t h e a r r i v a l of a ~yocardial i n f a r c t i o n - a r r e s t or m u l t i p l e t r a u m a p a t i e n t is a0t a time to get a d a t a base and problem list started. • .. I h e s i t a t e to reveal, in view of m y outspoken com~tment to e m e r g e n c y m e d i c i n e as a s e p a r a t e specialty, ithat local factors in m y e m p l o y m e n t and some desire to 'Studythe definability of emergency medicine versus family i~ractice have led me to t a k e the 1974 certification e x a m of lhe AAFP by special p e r m i s s i o n of t h e i r board. It is an solated factor a n d in no w a y obviates m y desire to be Ierhfied in m y specialty, e m e r g e n c y medicine, when this is ~Vallable.
I
Ouring t h e exam, I k e p t t r a c k of the subject m a t e r i a l a n d
~)
May/June 1975
divided the questions into t h r e e categories based on my experience in e m e r g e n c y medicine a n d f a m i l y practice. The first (EM) were those questions or case p r e s e n t a t i o n s t h a t involved subject m a t t e r b a s i c a l l y w i t h i n the province of e m e r g e n c y medicine and c e r t a i n l y u s u a l l y seen m the cont e x t of a n e m e r g e n c y d e p a r t m e n t . The second a r e a (B) was r e l e v a n t to both fields at l e a s t on a "need to know" basis. The t h i r d a r e a (FP) involved m a t e r i a l in no w a y r e l e v a n t to e m e r g e n c y medicine, such as p r e - m a r i t a l care, lmmunizations, and so forth. Below are the figures for the five sections of the test. Section A - - 1 2 5 Multiple Chmce Questions EM-17 (13.6%), B-40 (32.0%), FP-68 (54.5%) Section B - - 1 3 0 M u l t i p l e Choice P i c t o r i a l Questions EKGs, a u d i o g r a m s , X-rays, etc. EM-11 (8.5%), B-79 (60.8%), FP-40 (30.7%) Section C - - P a t i e n t M a n a g e m e n t - 1 2 p a t i e n t s EM-2 (16.7%), B-1 (8.3%), FP-9 (75%) Section D - - P a t i e n t M a n a g e m e n t - 1 3 p a t i e n t s EM-3 (23.1%), B-3 (23.1%), FP-7 (53.8%) Section E - - 1 2 5 Multiple Choice Questions EM-16 (13%), B-40 (32%), FP-69 (55%) I chose to be inclusive of a n y r e a s o n a b l e p r o b a b i l i t y t h a t a n i t e m should be i m p o r t a n t to e i t h e r f a m i l y practice or e m e r g e n c y medicine, r a t h e r t h a n exclusive, so the "both" c a t e g o r y is as high as is likely. Still it a p p e a r s Dr. Nesbitt's f i g u r e s of 15% u n i q u e to f a m i l y p r a c t i c e a n d 5% to e m e r g e n c y medicine are not s u p p o r t e d by the A A F P test m a t e r i a l . I f i r m l y hope t h a t t h e e m e r g e n c y m e d i c i n e boards will clearly more t h a n r e v e r s e the proportions of t e s t m a t e r i a l to f u r t h e r a s s u r e the d e l i n e a t i o n of these two specialties. I t r u s t t h a t both fields will continue to grow in p r o v e n value to our country's h e a l t h needs as compliment a r y r a t h e r t h a n competitive fields. K e v i n M. O'Keeffe, MD Denver General Hospital Denver, Colorado
Dr. Nesbitt Replies To the Editor: I a p p r e c i a t e the o p p o r t u n i t y to respond to K e v i n M. O'Keeffe, MD's letter. The first major point of difference t h a t Dr. O'Keeffe r a i s e s is in the allocation of percentages. T h e r e is no doubt t h a t the percentage of acute e m e r g e n c i e s v a r i e s from hosp i t a l to hospital. Statistics I have reviewed in the p a s t v a r i e d from 35% critical e m e r g e n c i e s to p e r h a p s as low as
Volume 4 Number 3 Page 247
1% or 2% for a small c o m m u n i t y hospital e m e r g e n c y d e p a r t m e n t - a m b u l a t o r y clinic type service. The 5% emergent - - 15% urgent figure I chose was based on a verbal quotation made by Karl G. Mangold, MD, who operates a large emergency physicians group, and who impresses me not only as an accurate statistician, but also as one who has statistics available from a fairly representative crosssection of emergency departments. Perhaps I did not make the point of my article as clear as I might have. I did not contest the fact that, philosophically, there should be a specialty of emergency medicine, or even t h a t t h e r e is a p e r s o n a l i t y d i f f e r e n c e b e t w e e n t h e emergency physician and the average family practitioner. I also agree t h a t there is a specific body of knowledge and expertise t h a t the emergency physician should have which is not shared with the family physician. I recognize that, although this body of knowledge is a small proportion of the total knowledge needed by the emergency physician, it is nonetheless of vital importance, and is the factor which identifies the physician as an emergency physician. However, the cold statistical fact remains t h a t the majority of medical care given by the emergency physician is multi-disciplinary, non-emergent, and of a type t h a t requires exactly the same academic knowledge as t h a t of a good family physician. Episodic and crisis-oriented care relates to the type of delivery, not the body of knowledge. Philosophically, both the emergency physician and the family physician should see the patient as a whole person in a social or family setting, not just as a deranged organ system, as m a n y specialists do. I firmly oppose fostering emergency medical care as a fragmented, episodic, and crisis-oriented specialty. Preventive emergency medicine and epidemiology are fields t h a t the emergency physician must be involved in. Comm u n i t y classes in first aid and resuscitation, disaster planning, dissemination of poison control information, drug and alcohol-related accident prevention are all aspects of preventive medicine t h a t are of concern to the emergency physician. Assuring adequate follow-up care is being involved to some extent in continuing care. Furthermore, the e m e r g e n c y p h y s i c i a n will r a p i d l y lose his a c a d e m i c perspective if he has no interest and makes no effort to follow the progress of patients he has cared-for in the emergency department. Dr. O'Keeffe's r e m a r k s about not getting a data base and starting a problem list surprised me a little. One of the lectures I give on '~Pitfalls in Emergency Medicine" emphasizes the need for doing just this. While one is not going to delay resuscitative efforts while this is being done, it should be done concurrently by someone. A d a t a base g a t h e r e d f r o m a m b u l a n c e d r i v e r s , police, r e l a t i v e s , and so forth, is essential for the proper t r e a t m e n t of the patient. I have seen a n u m b e r of instances where the t r e a t m e n t s t a r t e d was i n a p p r o p r i a t e because no one realized the necessity of getting a data base, eg, a 76-yearold semicomatose m a n who was treated for a myocardial infarct with cardiogenic shock when in fact he had nearly exsanguinated. This data was available from his d a u g h t e r who was standing just outside the t r e a t m e n t room. As for problem lists, I have seen patients leave the
Page 248 Volume 4 Number 3
emergency department with a major diagnosis on the ch. L and suffer serious consequences because other importS]i,, conditions were not clearly recorded as they would ha~']~, been on a problem list. We have just revised our 0~' emergency department record to specifically conform te-I data-base-problem-list format. ~' As to the test material on the American Board of Fa~ll Practice examination, I have no disagreement with htl! O Keeffe s figures. However, I feel t h a t the conclusio~ .,~Ie has drawn is erroneous. The examination is designed [0~] family practice, not emergency medicine. The emphasis on things important to family practice, not emerge~ medicine, and the proportion of emphasis would be (if at on the n u m b e r of emergent or urgent patients a fa~ physician would see and not how m a n y family pracl patients an emergency physician would see. These figur~ would be entirely different. I think Dr. O'Keeffe's figur~ give a great deal of support to my premise since 15% of questions concerned urgent or emergent conditions a~i 31.6% related to conditions likely to be treated in t~ emergency department. This indicates nearly a 50% eve lap in examination material. Even if emergency depar m e n t patient care followed this distribution (which doesn't), it would still represent a very significant overl~ c e r t a i n l y much more t h a n with any other specialty. In conclusion, I heartily agree with Dr. O'Keeffe thaq family practice and emergency medicine should be c0m plementary fields and not competitive fields of practice I also agree t h a t emergency medicine is a specialty in its own right and should be recognized as such. But because of the vast a m o u n t of common material and problems which the!~ share, I still feel t h a t a logical development would be t~ have emergency medicine and family practice share sepal rate and individual specialty status under some sort of~] ! American Board of'~Primary Care." m
William R. Nesbitt, MD Director, Emergency Medical Services University of California Sacramento Medical Center
DRUGS OF CHOICE FOR RAPID EMESIS To the Editor: My proposed slight modification (JACEP July/Augusl 1974, p 261) of David S. Rausten, MD's Apomorphlne Naloxone Controlled Rapid Emesis dosage table (JACEt J a n u a r y / F e b r u a r y 1973, D 45) was intended for tho~ emergency physicians who are not pediatricians. To kn0t t h a t a four-year-old weighs approximately 37 pounds I~ frequently easier to find out from a table t h a n to obtalr exact information from often hysterical parents. As a corollary to this, a one year study of poisonings w~ u n d e r t a k e n at Lake County Memorial Hospital (Wes1 using the modified Rausten-Ochs table. | Thirty-one poisoned patients, ,ages 18 months to 5'~ I years, were treated by this author with only three eme I failures, all due to delayed t r e a t m e n t of a phenothiazl~!
May/June 1975 ~
I
Two P hysiclans, having begun thetr careers in small town a n d m o v e d to practtcing e m e r g e n c y ~nedwtne ~n high volume emergency departments, compare ~ews on emergency medtctne as d~stinct from faintly praclttce. In the opinion of William R. Nesbttt, MD, the main ~fference between hts background and that of Kevin M. o'Keeffe, MD is that 0 Keeffe s "has tts advantages since tts contemporary and not easdy confused wtth the older mage of general practice and conditions as they existed efore there was a Board of F a m E y Practice or an American ~ollege of Emergency Physicians."
~eneral practtce
i
PHILOSOPHICAL DIFFERENCE ITo the Editor." Back in y o u r M a r c h / A p r i l 1974 i s s u e you h a d a n mergency F o r u m article, " E m e r g e n c y Medicine and F a m y Practice" by W i l l i a m Nesbitt, MD. Upon r e a d i n g it, as r Nesbitt suspected, I did not receive most of t h e coments with e n t h u s i a s m and in fact would seriously d~saee with some of his s t a t e m e n t s . While I feel that, as Dr. N e s b i t t says, t h e r e is some 'common g r o u n d to f a m i l y p r a c t i c e a n d e m e r g e n c y !me&cine, I would not allocate the same percentage he has. iM0re i m p o r t a n t l y , I feel t h e r e is a basic philosophical or ipersonality d i f f e r e n c e b e t w e e n f a m i l y p r a c t i c e a n d :emergency medicine as well as the considerable a m o u n t of distract bodies of knowledge. I also support t h e g r e a t need for a steady supply of f a m i l y practitioners for this nation. W h i l e I a m a d a m a n t in t h e essential differences b e t w e e n e m e r g e n c y medicine a n d family practice, t h e y m u s t interface and recognize each ~0thers due role I do not t h i n k it is u n i n t e n t i o n a l or to the discredit of e m e r g e n c y medicine to "foster the philosophy 0ffragmented, episodic, crises oriented care," nor is it to the "detriment of the p a t i e n t . " I recognize the ideal of comprehensive a n d p r e v e n t i v e c a r e b u t t h e a r r i v a l of a ~yocardial i n f a r c t i o n - a r r e s t or m u l t i p l e t r a u m a p a t i e n t is a0t a time to get a d a t a base and problem list started. • .. I h e s i t a t e to reveal, in view of m y outspoken com~tment to e m e r g e n c y m e d i c i n e as a s e p a r a t e specialty, ithat local factors in m y e m p l o y m e n t and some desire to 'Studythe definability of emergency medicine versus family i~ractice have led me to t a k e the 1974 certification e x a m of lhe AAFP by special p e r m i s s i o n of t h e i r board. It is an solated factor a n d in no w a y obviates m y desire to be Ierhfied in m y specialty, e m e r g e n c y medicine, when this is ~Vallable.
I
Ouring t h e exam, I k e p t t r a c k of the subject m a t e r i a l a n d
~)
May/June 1975
divided the questions into t h r e e categories based on my experience in e m e r g e n c y medicine a n d f a m i l y practice. The first (EM) were those questions or case p r e s e n t a t i o n s t h a t involved subject m a t t e r b a s i c a l l y w i t h i n the province of e m e r g e n c y medicine and c e r t a i n l y u s u a l l y seen m the cont e x t of a n e m e r g e n c y d e p a r t m e n t . The second a r e a (B) was r e l e v a n t to both fields at l e a s t on a "need to know" basis. The t h i r d a r e a (FP) involved m a t e r i a l in no w a y r e l e v a n t to e m e r g e n c y medicine, such as p r e - m a r i t a l care, lmmunizations, and so forth. Below are the figures for the five sections of the test. Section A - - 1 2 5 Multiple Chmce Questions EM-17 (13.6%), B-40 (32.0%), FP-68 (54.5%) Section B - - 1 3 0 M u l t i p l e Choice P i c t o r i a l Questions EKGs, a u d i o g r a m s , X-rays, etc. EM-11 (8.5%), B-79 (60.8%), FP-40 (30.7%) Section C - - P a t i e n t M a n a g e m e n t - 1 2 p a t i e n t s EM-2 (16.7%), B-1 (8.3%), FP-9 (75%) Section D - - P a t i e n t M a n a g e m e n t - 1 3 p a t i e n t s EM-3 (23.1%), B-3 (23.1%), FP-7 (53.8%) Section E - - 1 2 5 Multiple Choice Questions EM-16 (13%), B-40 (32%), FP-69 (55%) I chose to be inclusive of a n y r e a s o n a b l e p r o b a b i l i t y t h a t a n i t e m should be i m p o r t a n t to e i t h e r f a m i l y practice or e m e r g e n c y medicine, r a t h e r t h a n exclusive, so the "both" c a t e g o r y is as high as is likely. Still it a p p e a r s Dr. Nesbitt's f i g u r e s of 15% u n i q u e to f a m i l y p r a c t i c e a n d 5% to e m e r g e n c y medicine are not s u p p o r t e d by the A A F P test m a t e r i a l . I f i r m l y hope t h a t t h e e m e r g e n c y m e d i c i n e boards will clearly more t h a n r e v e r s e the proportions of t e s t m a t e r i a l to f u r t h e r a s s u r e the d e l i n e a t i o n of these two specialties. I t r u s t t h a t both fields will continue to grow in p r o v e n value to our country's h e a l t h needs as compliment a r y r a t h e r t h a n competitive fields. K e v i n M. O'Keeffe, MD Denver General Hospital Denver, Colorado
Dr. Nesbitt Replies To the Editor: I a p p r e c i a t e the o p p o r t u n i t y to respond to K e v i n M. O'Keeffe, MD's letter. The first major point of difference t h a t Dr. O'Keeffe r a i s e s is in the allocation of percentages. T h e r e is no doubt t h a t the percentage of acute e m e r g e n c i e s v a r i e s from hosp i t a l to hospital. Statistics I have reviewed in the p a s t v a r i e d from 35% critical e m e r g e n c i e s to p e r h a p s as low as
Volume 4 Number 3 Page 247
1% or 2% for a small c o m m u n i t y hospital e m e r g e n c y d e p a r t m e n t - a m b u l a t o r y clinic type service. The 5% emergent - - 15% urgent figure I chose was based on a verbal quotation made by Karl G. Mangold, MD, who operates a large emergency physicians group, and who impresses me not only as an accurate statistician, but also as one who has statistics available from a fairly representative crosssection of emergency departments. Perhaps I did not make the point of my article as clear as I might have. I did not contest the fact that, philosophically, there should be a specialty of emergency medicine, or even t h a t t h e r e is a p e r s o n a l i t y d i f f e r e n c e b e t w e e n t h e emergency physician and the average family practitioner. I also agree t h a t there is a specific body of knowledge and expertise t h a t the emergency physician should have which is not shared with the family physician. I recognize that, although this body of knowledge is a small proportion of the total knowledge needed by the emergency physician, it is nonetheless of vital importance, and is the factor which identifies the physician as an emergency physician. However, the cold statistical fact remains t h a t the majority of medical care given by the emergency physician is multi-disciplinary, non-emergent, and of a type t h a t requires exactly the same academic knowledge as t h a t of a good family physician. Episodic and crisis-oriented care relates to the type of delivery, not the body of knowledge. Philosophically, both the emergency physician and the family physician should see the patient as a whole person in a social or family setting, not just as a deranged organ system, as m a n y specialists do. I firmly oppose fostering emergency medical care as a fragmented, episodic, and crisis-oriented specialty. Preventive emergency medicine and epidemiology are fields t h a t the emergency physician must be involved in. Comm u n i t y classes in first aid and resuscitation, disaster planning, dissemination of poison control information, drug and alcohol-related accident prevention are all aspects of preventive medicine t h a t are of concern to the emergency physician. Assuring adequate follow-up care is being involved to some extent in continuing care. Furthermore, the e m e r g e n c y p h y s i c i a n will r a p i d l y lose his a c a d e m i c perspective if he has no interest and makes no effort to follow the progress of patients he has cared-for in the emergency department. Dr. O'Keeffe's r e m a r k s about not getting a data base and starting a problem list surprised me a little. One of the lectures I give on '~Pitfalls in Emergency Medicine" emphasizes the need for doing just this. While one is not going to delay resuscitative efforts while this is being done, it should be done concurrently by someone. A d a t a base g a t h e r e d f r o m a m b u l a n c e d r i v e r s , police, r e l a t i v e s , and so forth, is essential for the proper t r e a t m e n t of the patient. I have seen a n u m b e r of instances where the t r e a t m e n t s t a r t e d was i n a p p r o p r i a t e because no one realized the necessity of getting a data base, eg, a 76-yearold semicomatose m a n who was treated for a myocardial infarct with cardiogenic shock when in fact he had nearly exsanguinated. This data was available from his d a u g h t e r who was standing just outside the t r e a t m e n t room. As for problem lists, I have seen patients leave the
Page 248 Volume 4 Number 3
emergency department with a major diagnosis on the ch. L and suffer serious consequences because other importS]i,, conditions were not clearly recorded as they would ha~']~, been on a problem list. We have just revised our 0~' emergency department record to specifically conform te-I data-base-problem-list format. ~' As to the test material on the American Board of Fa~ll Practice examination, I have no disagreement with htl! O Keeffe s figures. However, I feel t h a t the conclusio~ .,~Ie has drawn is erroneous. The examination is designed [0~] family practice, not emergency medicine. The emphasis on things important to family practice, not emerge~ medicine, and the proportion of emphasis would be (if at on the n u m b e r of emergent or urgent patients a fa~ physician would see and not how m a n y family pracl patients an emergency physician would see. These figur~ would be entirely different. I think Dr. O'Keeffe's figur~ give a great deal of support to my premise since 15% of questions concerned urgent or emergent conditions a~i 31.6% related to conditions likely to be treated in t~ emergency department. This indicates nearly a 50% eve lap in examination material. Even if emergency depar m e n t patient care followed this distribution (which doesn't), it would still represent a very significant overl~ c e r t a i n l y much more t h a n with any other specialty. In conclusion, I heartily agree with Dr. O'Keeffe thaq family practice and emergency medicine should be c0m plementary fields and not competitive fields of practice I also agree t h a t emergency medicine is a specialty in its own right and should be recognized as such. But because of the vast a m o u n t of common material and problems which the!~ share, I still feel t h a t a logical development would be t~ have emergency medicine and family practice share sepal rate and individual specialty status under some sort of~] ! American Board of'~Primary Care." m
William R. Nesbitt, MD Director, Emergency Medical Services University of California Sacramento Medical Center
DRUGS OF CHOICE FOR RAPID EMESIS To the Editor: My proposed slight modification (JACEP July/Augusl 1974, p 261) of David S. Rausten, MD's Apomorphlne Naloxone Controlled Rapid Emesis dosage table (JACEt J a n u a r y / F e b r u a r y 1973, D 45) was intended for tho~ emergency physicians who are not pediatricians. To kn0t t h a t a four-year-old weighs approximately 37 pounds I~ frequently easier to find out from a table t h a n to obtalr exact information from often hysterical parents. As a corollary to this, a one year study of poisonings w~ u n d e r t a k e n at Lake County Memorial Hospital (Wes1 using the modified Rausten-Ochs table. | Thirty-one poisoned patients, ,ages 18 months to 5'~ I years, were treated by this author with only three eme I failures, all due to delayed t r e a t m e n t of a phenothiazl~!
May/June 1975 ~