I’m fresh back from the American College of Emergency Physicians Scientific Assembly.  Although I wrote this in September, the conversations I had with friends and readers at the convention confirm my observations.  I’m always afraid I’ll become a ‘one trick pony,’ complaining about life in the ER.  Or like the old saying, ‘when all you have is a hammer, all the world’s a nail.’  But looking in the eyes of colleagues, hearing their stories, I know that my job is to continue to advocate for those who staff emergency departments in America and around the world.  And I mean, doctors, nurses, medics and all the rest!



Emergency medicine, like every specialty, is it’s own religion. And on many levels, it tracks right along with the progression of religions from their ancient origins to their modern incarnations.

Our unique profession grew out of a pressing need for physicians who could provide immediate and life-saving care to the sick and injured, at all hours of the day or night. The goals of our early practitioners and advocates, our ‘patristic’ and ‘matristic’ founders was to ensure that we did the right research, trained in the right skills and brought them to a nation and world in dire need of high quality care in times of crisis. The early disciples, deeply committed to the early statements of faith, went forth and brought many into the fold. Our creed might have been this: ‘I believe in saving life and limb, anytime and anywhere, with all the skills I have. I believe that the doctor is accountable and responsible for leading, and acting, to accomplish this goal. Amen.’ Our catechism, our first Communion? Residency, oral and written boards. Our sacraments and liturgy were clear; history, exam, intubation, chest tubes, central lines, charcoal and the other skills which defined us. We held it sacred that we were accountable for the patients above all. Humans still dwelt at the center of our medical act of worship. We even accepted the idea that no one should be forced to pay for that care.

The gray on my head and in my beard testify that I have been a believer long enough to see the transformations that have led us, by degrees, away from our true faith and into heresies that blur the ways of old. Our religion thrives, on one level. Like shiny mega-churches, our residencies are the envy of many specialties. Medical students clamor for the excitement and immediacy of the ER; the thrill of lives saved and lost. Maybe they sense the apocalypse; they want to be on the right side when the end times come. Perhaps our young students and residents have prophetic gifts. America’s healthcare system is in barely controlled collapse right above its emergency departments, which will be the only thing to carry the day when the dark ages of medicine finally arrive.

To this day, the science, the medicine is good. We do amazing things. However, we have polluted our faith with too many rituals and rites, too many creeds and dogmas, too many liturgies. And our believers are burdened with unyielding laws, impossible to follow.

The rites of passage now? As before, but with more than in days of old. Yearly tests, yearly fees, tests each decade. An immersion in ‘evidence-based’ everything, to prove that we are skeptical about the right things. Ever more documents to show that those of us practicing are true followers, true acolytes. Forms to show we make people happy and attestations to prove we’re studying. Systems to show that we’ve squeezed all of the money out of every paying patient. We worship new minor deities in check boxes and programs, decision rules and systems and consultants.

The sacraments? Oh for simpler days. Now they include more and more complexity; time-outs and more passwords than we can recall. Warnings to check drugs and ask us if we’re allowed to see the chart and impossible algorithms for admission of the sick. And don’t forget that we must always reject the witches and sorcerers of industry, even as we embrace the billing practices of the hospital industry.

There are always new electronic systems to learn, and keyboards we caress like relics of the True Cross, screens we view with the intensity we once reserved for the human beings who came to us for care (how naïve we were).

But there are more. We honor the sacraments of pointless pain scales, we cringe in fear of the hell-fire promised if we violate EMTALA and HIPPA. We sing praises to patient satisfaction scores and meaningful use and we add more and more because in the new creed, humans are less important than ever and rules are the worn stairs by which we ascend the holy mountain. We have a managerial priesthood of administrators and consultants, federal regulators and rule-makers, state board functionaries and hospital overseers, background checkers and supervisors, the cost of whose collective salaries far eclipse our own and whose numbers dwarf ours as well.

The simple priests and missionaries of the early days are eclipsed by armies of men and women dressed in the vestments of a profession they barely understand but are happy to run. People who want to say they work ‘in medicine,’ but who never walked the old via dolorosa in the lonely hallways and trauma bays of endless shifts. Sadly, some of them did. But found ‘greener’ pastures in collecting indulgences from the rest of us.

So what is the new creed? ‘I believe in saving life and limb, at all hours of the day and night, and I will do it no matter how maligned I am. I believe that everyone who says ’emergency’ has an emergency. I believe that I must respect the diversity and bad choices of all and never condemn or appear to judge. I believe that I must always be attuned to satisfying customers, and to giving credence to everyone placed above me, whether nurse, secretary or administrator. I believe that I must work long and hard as an employee, and should never complain because I am a doctor now and have no reason to do so. I believe that forms and computer screens deserve my full attention. I believe that capturing data for billing is as important as comforting the sick. And I will always, always, do as I’m told.’

You see, the creed is ever more complex and we are, as in so many religions, widening the gulf from our origins and empowering the ‘churchistocracy’ above us.

I believe. I believed in it before and I do now. But we’ve lost our way. And now generations of believers will only see ridiculous rules and hypocritical leadership when they could have seen the wonder of life as a physician when we knew exactly what we were here to do. And were allowed to do it. We were dirty, and dusty and a little disorganized. But our hearts were on fire. Alas, times have changed.

And maybe, just maybe, it’s time for a reformation.

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