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.
I am commenting and I read it. You know I love reading whatever you write. Hope you are well.
Carole Alexander
8 years ago
Very well said…
Walter Jacquemin
8 years ago
At the meeting, did you see all the Emergency Physicians with their “deer in the headlights” eyes? Their sullen expressions and beaten demeanors? This is a far cry from the bright-eyed enthusiasm at the same meeting 15 years ago. Emergency medicine is being overwhelmed by the task of holding up the entire medical system. As you have stated, the Emergency Physician is cardiologist, orthopod, neurologist, psychiatrist…you name it. These salaried guys will no longer come in to help out, even though you are caring for the patients that they would not see in the office. The non-physician hospital people are… Read more »
Matt Zban
8 years ago
Nice article Ed. I’m all for a ‘Reformation’ in EM. However, I hope it is unlike the Protestant Reformation which was more like a revolution and divorce which led to >30,000 churches, not one unified reformed church. I would hate to see EM fractured like that.
An EM reformation, minus the divorce and splinter groups, would be a great feat.
Mike McGowan
8 years ago
Good article as always doc, keep up the good work. I so like to read what you have to say. Like many other institutions of whatever sort, they have all changed and seem to continue to degrade. I often wonder why we changed the way we do things. SO many times I see that the old tried and true ways seemed to work, but we have forsaken them, maybe for convenience or expedience and in doing so, end up with an unexpected result.
Mrs. George B. Shealy
8 years ago
I wish my husband could have lived to have read this article and many others you have written since he died. He was a great fan of yours. No truer words than these about the reformation of ER. I feel sorry for the doctors now who have so much paper work to do because they are made to do all of that. Thanks for the article. Gloria Shealy
Willie Franklin
8 years ago
i love this article. I say at work all the time while typing away at the computer: I’m too busy practicing medicine to see that next patient. We get it. Others don’t.
Lynn Rogers Dean
8 years ago
Dr. Leap, I look forward to reading all your blogs. Thank you for your honesty in every one I’ve read. I soooo agree with you concerning Doctors having to spend so much time on their computers that they barely have time to talk with patients during the visit. My Doctor is in another city and I don’t relish the idea that I must drive 2 hours round trip just to spend precious few minutes concerning my health problem. I must go out of town for a Doctor since my Internist in Seneca suddenly left the area and I had to… Read more »
doug gentry
8 years ago
Another great article. The question is how to bring about correction.
Howard Levitin
8 years ago
Good article – tough issues. Evidence based vs gestalt. Customer service data points vs just feel lucky I’m here. EMR vs Illegible charts and reviewing old records in paper form. EMTALA vs dumper beware. Pain scales to assess progress vs. whatever. Federal regulators vs. Snake Oil Salesman. Licensure requirements vs. Unmonitored quackery. Complaining vs. focused change. Religious dogma vs enlightenment. Personal pride vs furry. Leadership vs follower. Hospital overseer vs. financial instability. Standardization vs. rampant disregard. We don’t chose when and how we were born nor when and how we will die. We have a choice of what we do… Read more »
Kate R. Noriega
8 years ago
I do not know how I came across your blog, and truthfully , I am not an avid blog reader, however I could not resist the urge to tell you how loudly this resonates with me. Albeit, I am a PA, not a MD but I still find emergency medicine, even for me over the past few years particularly frustrating and extremely misguided by everyone but the provider. I no longer feel I play the biggest part in treating my patients , it’s the pharmaceutical companies , politicians, billing department , and the insurance companies that dictate a majority of… Read more »
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This sermon deserves a most hearty “amen.”
I am commenting and I read it. You know I love reading whatever you write. Hope you are well.
Very well said…
At the meeting, did you see all the Emergency Physicians with their “deer in the headlights” eyes? Their sullen expressions and beaten demeanors? This is a far cry from the bright-eyed enthusiasm at the same meeting 15 years ago. Emergency medicine is being overwhelmed by the task of holding up the entire medical system. As you have stated, the Emergency Physician is cardiologist, orthopod, neurologist, psychiatrist…you name it. These salaried guys will no longer come in to help out, even though you are caring for the patients that they would not see in the office. The non-physician hospital people are… Read more »
Nice article Ed. I’m all for a ‘Reformation’ in EM. However, I hope it is unlike the Protestant Reformation which was more like a revolution and divorce which led to >30,000 churches, not one unified reformed church. I would hate to see EM fractured like that.
An EM reformation, minus the divorce and splinter groups, would be a great feat.
Good article as always doc, keep up the good work. I so like to read what you have to say. Like many other institutions of whatever sort, they have all changed and seem to continue to degrade. I often wonder why we changed the way we do things. SO many times I see that the old tried and true ways seemed to work, but we have forsaken them, maybe for convenience or expedience and in doing so, end up with an unexpected result.
I wish my husband could have lived to have read this article and many others you have written since he died. He was a great fan of yours. No truer words than these about the reformation of ER. I feel sorry for the doctors now who have so much paper work to do because they are made to do all of that. Thanks for the article. Gloria Shealy
i love this article. I say at work all the time while typing away at the computer: I’m too busy practicing medicine to see that next patient. We get it. Others don’t.
Dr. Leap, I look forward to reading all your blogs. Thank you for your honesty in every one I’ve read. I soooo agree with you concerning Doctors having to spend so much time on their computers that they barely have time to talk with patients during the visit. My Doctor is in another city and I don’t relish the idea that I must drive 2 hours round trip just to spend precious few minutes concerning my health problem. I must go out of town for a Doctor since my Internist in Seneca suddenly left the area and I had to… Read more »
Another great article. The question is how to bring about correction.
Good article – tough issues. Evidence based vs gestalt. Customer service data points vs just feel lucky I’m here. EMR vs Illegible charts and reviewing old records in paper form. EMTALA vs dumper beware. Pain scales to assess progress vs. whatever. Federal regulators vs. Snake Oil Salesman. Licensure requirements vs. Unmonitored quackery. Complaining vs. focused change. Religious dogma vs enlightenment. Personal pride vs furry. Leadership vs follower. Hospital overseer vs. financial instability. Standardization vs. rampant disregard. We don’t chose when and how we were born nor when and how we will die. We have a choice of what we do… Read more »
I do not know how I came across your blog, and truthfully , I am not an avid blog reader, however I could not resist the urge to tell you how loudly this resonates with me. Albeit, I am a PA, not a MD but I still find emergency medicine, even for me over the past few years particularly frustrating and extremely misguided by everyone but the provider. I no longer feel I play the biggest part in treating my patients , it’s the pharmaceutical companies , politicians, billing department , and the insurance companies that dictate a majority of… Read more »