Passing the Torch: The Inheritance of Emergency Medicine

Passing the Torch: The Inheritance of Emergency Medicine Stanley R Gold, MD Claudia R Gold, MD Copyright © by the American College of Emergency Physicians.

Passing the Torch: The Inheritance of Emergency Medicine [Gold SR, Gold CR: Passing the torch: The inheritance of emergency medicine, Ann EmergMed October 1997;30:531-534.] When we realized that our former editor, Dr Stanley Gold, was one member of a unique pair of two-generation boarded emergency physicians, we asked him and his daughter, Dr Claudia Gold, to write about their experiences as emeNency physicians. It is fascinating to do this at this time, when there are, roughly, only two generations of such physicians. We wondered to what extent the spectrum of experiences of emergency medicine might be shared by them, and to what degree their views would differ. They have responded by writing letters to each other that are quite personal but may speak for many emergency physicians of both generations. Expecting a nostalgc look at how much has changed in 25 to 30years, we are struck by the similarities of experience they describe. What we are left with is a description of the passion inherent in emergency medicine, still burning in the heart of a new generation. Joseph Waeckerle, MD Ron Krome, MD John van de Leuv, MD, CM Dear Claudia, Among the mundane distractions of age 65--Medicare, 26cent coffee at McDonald's, tinnitus, access to the slitlamp to read Sanford's Antimicmbial Guide--I confess to relish my unique role as your dad and your fellow. This exclusive celebrity was acquired, unlike other sinecures, with a somewhat grudging acknowledgment by peers of my education, experience, and current competence. You recall, though, that I did have to take the ABEM examination and that despite my lacking the now-necessary education, I did have to pass it even if my score was a trifle lower than yours. Thanks again for all the encouragement. Let me here return the favor. Indulge my propensity for recalling things that didn't happen, and note that a long time ago you asked me what made me

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decide to become an emergency physician. Shades of Charlie Brown (or was it Lucy?) asking Snoopy why he decided to become a dog! I don't remember what I answered, but Snoopy claimed, "I was fooled by the job description." Never burdened with prescience, I had imagined that I had good intentions and noble goals, and contrived to mature them, while philosophers informed me that this is just not the way things are. The correct ontology is that action precedes design, and my actions and designs found no exception. I entered emergency medicine a fool to the job description. I recall running, as an intern, to respond to a "star" overhead page, in a time barely concomitant with the work on simultaneous closed-chest compression and mouth-tomouth ventilation of Jude and Kouwenhoven, my mind plagued and appalled with the question, "Why am I running? I haven't the ghost of an idea what to do when I get there!" Four years later (1967), modem CPR still largely unknown, I stood in an ER, entrusted to me by a nun who had more confidence in me than I had in myself, and noticed how few in medicine, or indeed in the world, seemed concerned about the many crises that were daily laid in our hands. There was little time for such musings then. Daily pressure to take effective action proved a useful distraction. Now, some 30 years later, slowed a bit by the battering stampede of emergency medicine into the forefront of medical specialties, I look at my job description and wonder at the fit. Certainly I now have the appurtenances, the trappings of a medical specialist, but what was sacrificed in their acquisition? Remember when I kept a spray can on my desk that you had given me as a gift? It was labeled "bullshit repellent," and I used it as protection from the enormous amount of rubbish and preposterous palaver that I encountered daily Well, I've lost my can of repellent. And without it, the din of "white noise" makes truth-seeking extremely difficult. The Anglican mage, Brother Roger Bacon, OFM, declared there were four stumbling blocks to truth: the influence of fragile or unworthy authority, custom, the imperfection of undisciplined senses, and concealment of ignorance by ostentation of seeming wisdom. In our early days, searching for our strengths, plunging ahead into uncharted territory, taking enormous risks, raising our sights above the limited horizons of medicine, we were standing tall over these blocks. In our new role of guardians of the faith, we are beginning to stumble over them. Our current tendency is to overdetermine standards of practice; to chart as though we were internists; to allow billing to dictate practices instead of the other way around; to blind ourselves to costs; to be smitten with the law of infinite-

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length queues (which declares the queue function most efficiently in the absence of service at its terminus); to fail to be sensitive to the abrasiveness of technology; to continually misinterpret the letters "CPR" to mean "cardiopulmonary resurrection"; to seek to institutionalize our compassion; to fail to remain mindful that we have a major but everchanging constituency, the public, that truly determines who we are, what we are, and how we are; and to fail to seek treatment of our serious "edifice complex," the delusion that hospitals are the creators of emergency medicine rather than the houses--not the only ones---in which we choose to reside. I am not opposed to stumbling. After all, we stumbled our way into the specialty, and stumbling often awakens us or opens our eyes to a potential blindness. It is life asking us to take note of something we missed, a little "aha." I want to offer you three such epiphanies that transformed my relationship to our specialty While m the throes of creation of a local trauma system, one that ended in financial and medical bankruptcy-though not much else in the way of individual salvage--I noticed a report of the near-50% decline in predicted highway trauma. Attributed to a reduction of the national speed limit, it was eclipsed by our annoyance with gasoline lines, high oil prices, and a general frustration with being required to slow down. Almost unnoticed was that it was a byproduct of a response of the United States Congress to an Arab oil embargo and designed to save precious fuel. Exactly which Arab country wished to lay claim to this phenomenal contribution to the alleviation of trauma was unclear, so I never wrote to thank them. Participating in a prospective study of the effect of regional EMS systems on the reduction of death and disability from life-threatening emergencies, I was shocked to discover that the number of truly life-threatening episodes occurring in the community was less than 10% of the number we had predicted. What kind of care do we plan and provide for the other 90%, and at what cost? Establishing a foothold in medical territory into which others had not yet ventured was our claim to fame. It took teamwork, and we quickly adopted the best of this sports metaphor, creating triage teams, resuscitation teams, trauma teams, and a host of others to focus the efforts of multiple caregivers on our areas of concern. Yet the public--by the nature of their injuries and ailments--staked out emergency medicine long before we did. So where are the "weak and dizzy" teams being called for today? Finally, I want to speak of burnout. You seem to worry about it occasionally, but it is actually just another kind of renewal. Think of it like the tale of the phoenix who rises,

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born anew, from the ashes of his funeral pyre. A fire can burn up all your dead wood at the same time. And it's the only way I know to get a good toasted marshmallow. Love, Dad

Dear Dad, You may not recall what you told me when I asked how you decided to become an emergency physician, but I do. You said you liked throwing yourself into situations in which the outcome was unpredictable. You defined an emergency physician as a doctor who enjoys arriving at the theater after the beginning of the movie and who maintains equanimity missing the denouement when forced to leave before the end. That was my introduction to the specialty. I knew you were doing it, even if neither of us knew exactly what it was, and you looked respectable. I was thus surprised to encounter resistance during medical school when I spoke of emergency medicine. Few understood it; most did not care to know much more. It seemed to have foes on all sides, or at least a shortage of vocal believers to defend or promote it. Nonetheless, emergency medicine appeared to gain ground and the respect of observers together, emerging rapidly as a viable and attractive career choice. And then, finally, it had arrived, and everyone seemed to be jumping on the EM bandwagon. It carved out territory that was of interest to everyone, not just those attracted to an EM career. But is the future of EM what it used to be ? I never cease to wonder how you still do what you do after 30 years, with endurance and enjoyment, while "does" half your age are already whining about stress and burnout. I'm convinced that younger "ER docs" don't appreciate what your generation went through to get us where we are today. Many think you had it easy back then, without the current obstacles we face. But I remember your telling me how you had to walk to work, uphill, both ways, barefoot, 2 miles in the snow, through those miserable Southern California winters, to cover your ED when no one else would do it. I would certainly never minimize those important historical achievements, but the battles you fought are not what we face today. The struggles demand the same energy, but the foes are cloaked in different armor. What's different today? Our allies, for one; we are now aligned with many colleagues in organized medicine who once were staunch opponents. Our enemies, for another: nonmedical structures, agencies and institutions, publicly traded vehicles, HMOs, hospital corporations, managed care organizations, with their staffs of too many nonphysicians

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making physician's decisions and shaping our practice in most unattractive ways. What happened to common sense, to judgment, to clinical judgment? And how about payment? Once only the indigent ignored our bills. Now well-heeled clients, insurance companies, and profitable HMOs refuse, downcode, or delay payment. We are unique the only physicians qualified and willing to do what we do, and we're damned good at it, despite Monday morning quarterbacking! My favorite lesson in residency was Gerry Whelan's command, "Just do the right thing!" It applies to everything in life and takes diligence but is always worth the effort. All we really want to do is to take care of people, to "do the right thing." After all, don't we represent the patient's interests? And don't those interests take precedence? Let's get back to what "doctoring" is all about. Are we really better off with all our new and dazzling technology, or simply shackled to it? Isn't there something wrong when we discover that we can be "right" 95% of the time just by declaring every x-ray we order "negative"? Now to the practice. Loves: It's a thrill! I thrive in the chaos, the "A-fib lifes@e," the freedom of practice patterns and schedules, the excitement of variety, the social stimulation, the potential to always be busy, and to always need to know more. Hates: Dealing with the daily "beast," the bureaucracy, paperwork, unmanageable managed care, and legal beagles. Our specialty is being watched, haunted, scrutinized, inspected, sniped at, and dissected by an endless army of people who seem hell-bent on making simple common-sense things difficult. But it's not all doom and gloom. We find opportunity in every corner. We're not afraid to try new things, not afraid to be wrong. Promise is seen in many of our leaders who fight to protect our causes and have the courage to publicly declare what many may be thinking but are afraid to say. So, as a specialty, where are we going now? Only time will tell. But time has proved us to be an innovative bunch in the face of challenges. By nature we are a group of doers, of risk-takers and decisionmakers, often with limited data and fuzzy sets. It is our ability to be open and flexible and to prosper in times of chaos that has allowed us to evolve much faster than other disciplines. Medicine will continue to change, and we will be more responsive to it. We can and do see the light, and we will continue to do the right thing. Here's to all the pioneers of our specialty who were willing to go all out, to go the distance, and to continually seek a better way. Many of us out there follow in your footsteps. Maybe the future is what it used to be. Love, Claudia

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Editorial Boards, 1984-1987

1986

1984

Editor Ronald L Krome, MD

Editor Ronald L Krome, MD

Associate Editor Michael E Callaham, MD

Associate Editor Joseph F Waeckerle, MD

Associate Editor Emeritus Carl Jelenko III, MD

Editorial Board Gail V Anderson, MD Richard E Burney, MD Michael L Callaham, MD L Eugene Dagnone, MD Stanley R Gold, MD Harold A Jayne, MD William H Johnson, MD Robert K Knopp, MD Harvey W Meislin, MD James D Mills, MD James T Niemann, MD George Podgorny, MD Robert J Rothstein, MD Judith E Tintinalli, MD John H van de Leuv, MD, CM Michael V Vance, MD, MD Barry W Wolcott, MD

Editorial Board Gail V Anderson, MD Brooks F Bock, MD Richard E Burney, MD L Eugene Dagnone, MD Harold A Jayne, MD William H Johnson, MD Robert K Knopp, MD Harvey W Meislin, MD James D Mills, MD James T Niemann, MD George Podgorny, MD Robert J Rothstein, MD Judith E Tintinalli, MD John H van de Leuv, MD, CM Joseph F Waeckerle, MD Barry W Wolcott, MD

ConsultingEditors

1987

William F Bouzarth, MD John H Harris Jr, MD Barry Rumack, MD

Editor Ronald L Krome, MD

1985

Associate Editor Michael L Callaham, MD

Editor Ronald L Krome, MD

Associate Editor Emeritus Carl Jelenki III, MD

Associate Editor Joseph F Waeckerle, MD

Editorial Board LarryJ Baraff, MD Brooks F Bock, MD Richard E Burney, MD Richard H Cales, MD L Eugene Dagnone, MD Richard F Edlich, MD Robert K Knopp, MD Harvey W Metslin, MD James D Mills, MD James T Niemann, MD George Podgorny, MD Robert J Rothstein, MD Judith E Tintinalli, MD John H van de Leuv, MD, CM Michael V Vance, MD Joseph F Waeckerle, MD Barry W Wolcott, MD

Associate Editor Michael L Callaham, MD Associate Editor Emeritus Carl Jelenko III, MD Editorial Board Gall V Anderson, MD Brooks F Bock, MD Richard E Burney, MD L Eugene Dagnone, MD Stanley R Gold, MD Harold A Jayne, MD William H Johnson, MD Robert K Knopp, MD Harvey W Meislin, MD James D Mills, MD

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James T Niemann, MD George Podgorny, MD Robert J Rothstein, MD Judith E Tintinalli, MD John H van de Leuv, MD, CM Michael V Vance, MD Barry W Wolcott, MD

ConsultingEditors William F Bouzarth, MD John H Harris Jr, MD Barry Rumack, MD

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