- Email: [email protected]
‘ER doc’—requiem for an anachronism
The Journal of Emergency Medicine, Vol. 26, No. 4, pp. 457– 459, 2004 Copyright © 2004 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/04 $–see front matter
doi:10.1016/j.jemermed.2004.01.009
Editorial e ‘ER DOC’—REQUIEM FOR AN ANACHRONISM
skills, to garner the respect of medical staffs generally bestowed upon recognized medical specialties. This led to the term ‘ER doc’ becoming synonymous, in the minds of many physicians, with a lesser level of training and medical expertise. Working in the ‘ER’ was perceived in many circles as a bottom-of-the-barrel medical experience and the term ‘ER doc’ took on a somewhat denigrating connotation that spawned other descriptive terms such as ‘eternal intern’ and ‘loser medicine’ (7,8). Unfortunately, despite nearly two decades of EM’s recognition as a medical specialty, this image still persists, and those of us in EM must strive to eliminate this image. If we examine the term ‘ER doc’ from a semantics’ perspective, it becomes even more apparent that this descriptive is not only without merit, but nonsensical as well. For example, no other medical specialty in the United States is described by an architectural term; we do not refer to surgeons as “operating room doctors (‘OR docs’), nephrologists as “dialysis suite doctors (‘DS docs’), nor obstetricians as “delivery room doctors (‘DL docs’), and the same should hold true for emergency physicians (5,9). Even from a purely architectural standpoint, ‘ER doc’ is a nonsequitur in that it is rare today that anyone practices EM in a single room; rather, we work in Emergency Departments or Emergency Centers (10). To those not in the medical profession and thus unfamiliar with medical jargon, an Emergency Room Doctor might conjure up thoughts of a tradesman who repairs rooms in an urgent fashion (e.g., a plumber fixing a leak that is flooding a basement would be an Emergency Room Doctor). From my perspective, Norm Abrams, the master carpenter of public television fame (“This Old House”) is the quintessential ‘Emergency Room Doctor.’ Even medical practitioners who believe that we should retain the term ‘ER’ to describe our work environment do not believe that we should be called ‘ER docs’ (9). Unfortunately, the two terms ‘ER’ and ‘ER doc’ are so intertwined that use of one automatically perpetuates use of the other. From a professional standpoint, some may opine that, with the myriad problems we face in EM today, making such a fuss over a seemingly minor point on terminology is hardly worth the effort. However, proper terminology, in any forum, is important. Professional titles are necessary for identifying individuals and the responsibilities
Recently, I received a call regarding a patient transfer from a physician at a nearby academic medical center that houses an Emergency Medicine residency program. The caller identified himself as the ‘ER resident’ on duty. After discussing the transfer, I made a point of informing him that I thought his choice of a professional descriptive was archaic, denigrating to the specialty, and that the proper term was an Emergency Medicine resident physician. Nonplussed, his response was that he was aware that “some Attendings are ‘hung up’ on the use of ‘ER doc’.” Having graduated from an EM residency program 20 years ago, at a time when the specialty was fighting for its recognition and existence, I found it especially disappointing that, in this day and age, a resident physician in our now-established specialty could be so cavalier about using the term ‘ER doc.’ My degree of dismay and disappointment is proportionally increased when I read of a past president of one of the specialty societies in Emergency Medicine (EM), himself an EM residency graduate, using this anachronism, especially in light of the fact that the specialty society he presided over has banned the use of the term “ER” from its official publication (1). Use of appropriate professional descriptives for Emergency Medicine and its practitioners is not a new concern and continues to be a topic of discussion and debate in the United States and other countries (2– 4). Historically, the term ‘ER’ derives from the fact that, before the 1960s, a hospital’s emergency service area was indeed very likely to be but a solitary room; hence, an ‘ER.’ During this very same time period, years before the development and recognition of Emergency Medicine (EM) as a medical specialty, physicians staffing the ‘ER,’ for lack of a better term, began to be routinely designated as ‘ER docs.’ These units were manned either voluntarily by a rather broad spectrum of temporary or second-career physicians from varied backgrounds, or through conscription (e.g., as part of the requirement for staff privileges), so that staffing was frequently accomplished more by availability and willingness than by competency (5–7). Not surprisingly, it was difficult for these physicians, with variable clinical and emergency 457
458
inherent to their respective positions. This is why we use such titles as doctor, officer, judge, etc. ‘ER doc’ is clearly not a professional title and emits a sense of lack of pride in the specialty. This is an especially important issue in EM, a specialty that continues to have an image problem that ultimately can have a negative impact on its practitioners (11). A medical specialty should attempt to foster respect for itself, and this should begin incrementally with some very basic issues upon which to build a reputable foundation. One such fundamental step, a small but necessary component of developing the appropriate image, is the use of a proper title to define our practitioners and their work environment. As Henry David Thoreau once noted, “With a knowledge of the name comes a more distinct recognition and knowledge of the thing.” [quoted in (10)]. Semantics are important in this respect and we should insist upon being called by our proper title, ‘emergency physician.’ (12). Unfortunately, in this respect, to paraphrase an old adage, “We have met the enemy and it is us.” All too often, I hear emergency physicians referring to themselves as ‘ER docs.’ Emergency physicians are used to multitasking and using shortcuts, and it may be that the shortened designation, ‘ER doc’, is a subconscious ramification of those processes. Perhaps, for some emergency practitioners, the term ‘ER doc’ has more flare and panache than the somewhat more staid ‘emergency physician,’ or it rolls off the tongue more easily. Oftentimes, I hear ‘ER doc’ used by older physicians who have utilized this term throughout their careers and old habits are difficult to change. I also frequently hear this term from non-residency-trained emergency physicians working in EDs. Perhaps this is because they have not been exposed to the esprit-de-corps of an EM residency program and its emphasis on developing specialty recognition. In the 1980s, as EM residency programs began to increase and expand, the preferred terms “emergency physician” or “emergency medicine physician” began to take hold. Many EM residency directors instilled the notion of the use of this nomenclature into their resident classes in the hope of bringing respect to this developing specialty. Resident physicians from other services, rotating in the ED, heard this name change and some of them adopted its use. As further recognition of the fact that ‘ER doc’ is not an acceptable term for practitioners of the specialty, all the major U.S. peer-reviewed emergency journals (i.e., Journal of Emergency Medicine, Annals of Emergency Medicine, American Journal of Emergency Medicine, Academic Emergency Medicine) banned the use of this term in their journals due to its negative connotations (although, unfortunately, non-peer-reviewed emergency journals continue to use this term) (12). Similarly, EM specialty societies [American Academy of Emergency Medicine (AAEM), American College of Emergency
The Journal of Emergency Medicine
Physicians (ACEP)] have codified the appropriate term, emergency physician, in their bylaws (13). With this groundswell of name change taking place, it seemed that the term ‘ER doc’ was on its way to being relegated to a mere footnote in the history of the development of EM. Then, quite without warning, a seminal event occurred that reversed this course of name change; namely, the introduction of the enormously popular television series, ‘ER,’ that possibly is watched by a majority of ED patients (14). All the years of effort by those of us who recognized the need for proper terminology to describe our specialist physicians and their work environments were wiped out in the flash of an eye by a television series that seems intent on developing and highlighting an unrealistic Hollywood mentality to the specialty of EM. Given the long-term ongoing popularity of the series, the terms ‘ER’ and ‘ER doc’ have been widely resurrected among practitioners and the public alike. Alas, Hollywood has undone in a brief time what it took our specialty years to attempt to change! Whatever the reasons for the use of the terms ‘ER’ and ‘ER doc,’ they subtly reinforce negative stereotypes about EM. Unfortunately, if you use inappropriate terms long enough, they become a part of the lexicon and perpetuate unfounded concepts. Use of the appropriate professional terminology should be a basic tenet that is the initial starting point for image enhancement. How then can we reverse the trend of use of the interwoven terms ‘ER’ and ‘ER doc’? Initially, and most importantly, all of us in EM should insist upon the appropriate use of the accepted term, ‘emergency physician.’ If we, in the profession, do not use the proper nomenclature ourselves, how can we expect other practitioners to do so? When someone calls us an ‘ER Doc,’ we should offer a gentle reminder that we are ‘emergency physicians.’ Perhaps the easiest and most far-reaching maneuver is to insist that ED unit secretaries answer the phones with the proper term, ‘Emergency Department.’ Given the volume of phone traffic in the average ED, this will ensure the farthest dissemination of the appropriate terminology for our work environment and eliminate ‘ER’ from the jargon. Contacting hospital administrators about changing signs that direct patients to the ‘Emergency Room’ in favor of those that say ‘Emergency Department,’ ‘Emergency Center,’ or just ‘Emergency’ is another step in the process. Numerous Emmy nominations have caused me to give up on the notion that the life span of ‘ER’ is soon coming to an end, so petitioning Hollywood to change the title of the show to ‘ED’ is not an option. However, I have had occasion to contact local news stations and journalists regarding the improper use of the terms ‘ER’ or ‘ER doctor’ and would urge others to do so. Residency directors in EM should insist upon use of the titles
Requiem for an Anachronism
‘emergency medicine resident’ and ‘emergency physician’ by their residents and residency attending staff. Physician subscribers should inform the editors of nonpeer-reviewed emergency journals that the use of the terms ‘ER’ or ‘ER doctor’ is unacceptable. At a time when EM is being negatively acted upon by so many disruptive forces (e.g., EMTALA, control of the specialty by contract management groups, decreasing reimbursements, malpractice), we need to be certain that we continue our attempts to foster respect for our specialty. Use of proper descriptive terminology is one such small, but necessary step. It is time to place a DNR (do not resuscitate) order on the use of the terms ‘ER’ and ‘ER doc’ once and for all. What’s in a name—indeed! Raymond Roberge, MD, MPH, FAAEM, FACMT Emergency Department Magee Women’s Hospital Pittsburgh, Pennsylvania REFERENCES 1. Carius M. Standing together. Emerg Physicians Mon 2003;10:4.
459 2. Muller HA. Emergency, emergentology, emergentologist. JACEP 1978;7:29 –31. 3. Sakr M, Wardrope J. Casualty, accident and emergency, or emergency medicine, the evolution. J Accid Emerg Med 2000;17: 314 –9. 4. Reid C, Chan L. Emergency medicine terminology in the United Kingdom—time to follow the trend? Emerg Med J 2001;18:79 – 80. 5. Roberge RJ. Emergency physicians. Am J Emerg Med 1988;6: 200. 6. Clinton JE. The “ER” and its “Doc” have changed: the specialty of emergency medicine. Minn Med 1988;71:677–9. 7. Logan D, Plaster ML. Emergency medicine: two views. Emerg Physicians Mon 2003;10:1,3,18,28. 8. Scheck A. For one eminent EP, it’s all about being challenged. Emerg Med News 2003;25:6. 9. Sternbach G. Time to be a room again? J Emerg Med 1986;4:409 – 10. 10. Almeida SL. What’s in a name? J Emerg Nurs 2002;28:101–2. 11. Frumkin K. “What’s in a name?,” “Moonlighting for fun and profit:” reflections on the state of emergency medicine—a goal for 2000 and beyond. Ann Emerg Med 1992;21:862– 4. 12. White JD. Editorial. Am J Emerg Med 1988;6:200. 13. Definition of emergency medicine and the emergency physician. American College of Emergency Physicians. Ann Emerg Med 1986;15:1240 –1. 14. Olsen JC, Johnson BC, Brown AM, Levinson SR. Patient perceptions of the specialty of emergency medicine. Am J Emerg Med 2000;18:278 – 81.
doi:10.1016/j.jemermed.2004.01.009
Editorial e ‘ER DOC’—REQUIEM FOR AN ANACHRONISM
skills, to garner the respect of medical staffs generally bestowed upon recognized medical specialties. This led to the term ‘ER doc’ becoming synonymous, in the minds of many physicians, with a lesser level of training and medical expertise. Working in the ‘ER’ was perceived in many circles as a bottom-of-the-barrel medical experience and the term ‘ER doc’ took on a somewhat denigrating connotation that spawned other descriptive terms such as ‘eternal intern’ and ‘loser medicine’ (7,8). Unfortunately, despite nearly two decades of EM’s recognition as a medical specialty, this image still persists, and those of us in EM must strive to eliminate this image. If we examine the term ‘ER doc’ from a semantics’ perspective, it becomes even more apparent that this descriptive is not only without merit, but nonsensical as well. For example, no other medical specialty in the United States is described by an architectural term; we do not refer to surgeons as “operating room doctors (‘OR docs’), nephrologists as “dialysis suite doctors (‘DS docs’), nor obstetricians as “delivery room doctors (‘DL docs’), and the same should hold true for emergency physicians (5,9). Even from a purely architectural standpoint, ‘ER doc’ is a nonsequitur in that it is rare today that anyone practices EM in a single room; rather, we work in Emergency Departments or Emergency Centers (10). To those not in the medical profession and thus unfamiliar with medical jargon, an Emergency Room Doctor might conjure up thoughts of a tradesman who repairs rooms in an urgent fashion (e.g., a plumber fixing a leak that is flooding a basement would be an Emergency Room Doctor). From my perspective, Norm Abrams, the master carpenter of public television fame (“This Old House”) is the quintessential ‘Emergency Room Doctor.’ Even medical practitioners who believe that we should retain the term ‘ER’ to describe our work environment do not believe that we should be called ‘ER docs’ (9). Unfortunately, the two terms ‘ER’ and ‘ER doc’ are so intertwined that use of one automatically perpetuates use of the other. From a professional standpoint, some may opine that, with the myriad problems we face in EM today, making such a fuss over a seemingly minor point on terminology is hardly worth the effort. However, proper terminology, in any forum, is important. Professional titles are necessary for identifying individuals and the responsibilities
Recently, I received a call regarding a patient transfer from a physician at a nearby academic medical center that houses an Emergency Medicine residency program. The caller identified himself as the ‘ER resident’ on duty. After discussing the transfer, I made a point of informing him that I thought his choice of a professional descriptive was archaic, denigrating to the specialty, and that the proper term was an Emergency Medicine resident physician. Nonplussed, his response was that he was aware that “some Attendings are ‘hung up’ on the use of ‘ER doc’.” Having graduated from an EM residency program 20 years ago, at a time when the specialty was fighting for its recognition and existence, I found it especially disappointing that, in this day and age, a resident physician in our now-established specialty could be so cavalier about using the term ‘ER doc.’ My degree of dismay and disappointment is proportionally increased when I read of a past president of one of the specialty societies in Emergency Medicine (EM), himself an EM residency graduate, using this anachronism, especially in light of the fact that the specialty society he presided over has banned the use of the term “ER” from its official publication (1). Use of appropriate professional descriptives for Emergency Medicine and its practitioners is not a new concern and continues to be a topic of discussion and debate in the United States and other countries (2– 4). Historically, the term ‘ER’ derives from the fact that, before the 1960s, a hospital’s emergency service area was indeed very likely to be but a solitary room; hence, an ‘ER.’ During this very same time period, years before the development and recognition of Emergency Medicine (EM) as a medical specialty, physicians staffing the ‘ER,’ for lack of a better term, began to be routinely designated as ‘ER docs.’ These units were manned either voluntarily by a rather broad spectrum of temporary or second-career physicians from varied backgrounds, or through conscription (e.g., as part of the requirement for staff privileges), so that staffing was frequently accomplished more by availability and willingness than by competency (5–7). Not surprisingly, it was difficult for these physicians, with variable clinical and emergency 457
458
inherent to their respective positions. This is why we use such titles as doctor, officer, judge, etc. ‘ER doc’ is clearly not a professional title and emits a sense of lack of pride in the specialty. This is an especially important issue in EM, a specialty that continues to have an image problem that ultimately can have a negative impact on its practitioners (11). A medical specialty should attempt to foster respect for itself, and this should begin incrementally with some very basic issues upon which to build a reputable foundation. One such fundamental step, a small but necessary component of developing the appropriate image, is the use of a proper title to define our practitioners and their work environment. As Henry David Thoreau once noted, “With a knowledge of the name comes a more distinct recognition and knowledge of the thing.” [quoted in (10)]. Semantics are important in this respect and we should insist upon being called by our proper title, ‘emergency physician.’ (12). Unfortunately, in this respect, to paraphrase an old adage, “We have met the enemy and it is us.” All too often, I hear emergency physicians referring to themselves as ‘ER docs.’ Emergency physicians are used to multitasking and using shortcuts, and it may be that the shortened designation, ‘ER doc’, is a subconscious ramification of those processes. Perhaps, for some emergency practitioners, the term ‘ER doc’ has more flare and panache than the somewhat more staid ‘emergency physician,’ or it rolls off the tongue more easily. Oftentimes, I hear ‘ER doc’ used by older physicians who have utilized this term throughout their careers and old habits are difficult to change. I also frequently hear this term from non-residency-trained emergency physicians working in EDs. Perhaps this is because they have not been exposed to the esprit-de-corps of an EM residency program and its emphasis on developing specialty recognition. In the 1980s, as EM residency programs began to increase and expand, the preferred terms “emergency physician” or “emergency medicine physician” began to take hold. Many EM residency directors instilled the notion of the use of this nomenclature into their resident classes in the hope of bringing respect to this developing specialty. Resident physicians from other services, rotating in the ED, heard this name change and some of them adopted its use. As further recognition of the fact that ‘ER doc’ is not an acceptable term for practitioners of the specialty, all the major U.S. peer-reviewed emergency journals (i.e., Journal of Emergency Medicine, Annals of Emergency Medicine, American Journal of Emergency Medicine, Academic Emergency Medicine) banned the use of this term in their journals due to its negative connotations (although, unfortunately, non-peer-reviewed emergency journals continue to use this term) (12). Similarly, EM specialty societies [American Academy of Emergency Medicine (AAEM), American College of Emergency
The Journal of Emergency Medicine
Physicians (ACEP)] have codified the appropriate term, emergency physician, in their bylaws (13). With this groundswell of name change taking place, it seemed that the term ‘ER doc’ was on its way to being relegated to a mere footnote in the history of the development of EM. Then, quite without warning, a seminal event occurred that reversed this course of name change; namely, the introduction of the enormously popular television series, ‘ER,’ that possibly is watched by a majority of ED patients (14). All the years of effort by those of us who recognized the need for proper terminology to describe our specialist physicians and their work environments were wiped out in the flash of an eye by a television series that seems intent on developing and highlighting an unrealistic Hollywood mentality to the specialty of EM. Given the long-term ongoing popularity of the series, the terms ‘ER’ and ‘ER doc’ have been widely resurrected among practitioners and the public alike. Alas, Hollywood has undone in a brief time what it took our specialty years to attempt to change! Whatever the reasons for the use of the terms ‘ER’ and ‘ER doc,’ they subtly reinforce negative stereotypes about EM. Unfortunately, if you use inappropriate terms long enough, they become a part of the lexicon and perpetuate unfounded concepts. Use of the appropriate professional terminology should be a basic tenet that is the initial starting point for image enhancement. How then can we reverse the trend of use of the interwoven terms ‘ER’ and ‘ER doc’? Initially, and most importantly, all of us in EM should insist upon the appropriate use of the accepted term, ‘emergency physician.’ If we, in the profession, do not use the proper nomenclature ourselves, how can we expect other practitioners to do so? When someone calls us an ‘ER Doc,’ we should offer a gentle reminder that we are ‘emergency physicians.’ Perhaps the easiest and most far-reaching maneuver is to insist that ED unit secretaries answer the phones with the proper term, ‘Emergency Department.’ Given the volume of phone traffic in the average ED, this will ensure the farthest dissemination of the appropriate terminology for our work environment and eliminate ‘ER’ from the jargon. Contacting hospital administrators about changing signs that direct patients to the ‘Emergency Room’ in favor of those that say ‘Emergency Department,’ ‘Emergency Center,’ or just ‘Emergency’ is another step in the process. Numerous Emmy nominations have caused me to give up on the notion that the life span of ‘ER’ is soon coming to an end, so petitioning Hollywood to change the title of the show to ‘ED’ is not an option. However, I have had occasion to contact local news stations and journalists regarding the improper use of the terms ‘ER’ or ‘ER doctor’ and would urge others to do so. Residency directors in EM should insist upon use of the titles
Requiem for an Anachronism
‘emergency medicine resident’ and ‘emergency physician’ by their residents and residency attending staff. Physician subscribers should inform the editors of nonpeer-reviewed emergency journals that the use of the terms ‘ER’ or ‘ER doctor’ is unacceptable. At a time when EM is being negatively acted upon by so many disruptive forces (e.g., EMTALA, control of the specialty by contract management groups, decreasing reimbursements, malpractice), we need to be certain that we continue our attempts to foster respect for our specialty. Use of proper descriptive terminology is one such small, but necessary step. It is time to place a DNR (do not resuscitate) order on the use of the terms ‘ER’ and ‘ER doc’ once and for all. What’s in a name—indeed! Raymond Roberge, MD, MPH, FAAEM, FACMT Emergency Department Magee Women’s Hospital Pittsburgh, Pennsylvania REFERENCES 1. Carius M. Standing together. Emerg Physicians Mon 2003;10:4.
459 2. Muller HA. Emergency, emergentology, emergentologist. JACEP 1978;7:29 –31. 3. Sakr M, Wardrope J. Casualty, accident and emergency, or emergency medicine, the evolution. J Accid Emerg Med 2000;17: 314 –9. 4. Reid C, Chan L. Emergency medicine terminology in the United Kingdom—time to follow the trend? Emerg Med J 2001;18:79 – 80. 5. Roberge RJ. Emergency physicians. Am J Emerg Med 1988;6: 200. 6. Clinton JE. The “ER” and its “Doc” have changed: the specialty of emergency medicine. Minn Med 1988;71:677–9. 7. Logan D, Plaster ML. Emergency medicine: two views. Emerg Physicians Mon 2003;10:1,3,18,28. 8. Scheck A. For one eminent EP, it’s all about being challenged. Emerg Med News 2003;25:6. 9. Sternbach G. Time to be a room again? J Emerg Med 1986;4:409 – 10. 10. Almeida SL. What’s in a name? J Emerg Nurs 2002;28:101–2. 11. Frumkin K. “What’s in a name?,” “Moonlighting for fun and profit:” reflections on the state of emergency medicine—a goal for 2000 and beyond. Ann Emerg Med 1992;21:862– 4. 12. White JD. Editorial. Am J Emerg Med 1988;6:200. 13. Definition of emergency medicine and the emergency physician. American College of Emergency Physicians. Ann Emerg Med 1986;15:1240 –1. 14. Olsen JC, Johnson BC, Brown AM, Levinson SR. Patient perceptions of the specialty of emergency medicine. Am J Emerg Med 2000;18:278 – 81.