Great treatment of a really bold topic. I’ve been wondering for years when we’d start talking about this. Thanks.

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I actually like the idea of integrating family practice (urgent care) into the “Emergency Department Medicine” model…and do agree that large portions of the emergency medicine paradigm are failing. Take a look at the free-standing ED models in CO & TX…they’re rampant and expanding like rabbits! This perfectly embodies how “emergent” care is being overrun by “urgent” care, and the need for rapid, self-focused, chronic care is overpowering the current system. What’s most alarming about this current paradigm/model is that we’re allowing it to fail (ie: free-standing EDs, not focusing on mobile integrated healthcare from the healthcare perspective, not by utilizing EMS).

Great talk Scott,

I think a major problem for Emergency Medicine as such to find its place as resuscitation medicine is that the need only actually exist at major hospitals in major cities. In hospitals with up-take areas of 1-2 million or smaller, which will be most hospitals, the number of proper emergencies will be too small to have a resuscitationist in the A&E, an intensivist in the intensive care unit, and an anaesthetist who lives in the OR. For most hospitals it is reasonable to have one or two critical care doctors that handle the ICU, in-hospital emergencies and resuscitation in the A&E, In the latter case, together with what you call emergency department medicine doctors who can also handle all the other stuff that flows through. A separate resuscitation-only emergency department is simply not feasible outside the absolutely largest of hospitals.

M

Scott,

Where is this utopia of multiple patients with deranged physiology you speak of. I want to work there. In 1989 I did a EM rotation at Denver General. My first day got in on a thracotomy which lasted 15 minutes, then walked over to the McDonalds in the hospital and got some French fries. Thoracotomy and McDonalds fries in the same building- I’m sold. I have learned to adjust to the real world practice of the not really sick. But I will race my partners to the room for a truly sick patient.
Thank you for all that you do. It adds to my professional happiness.

Jim

Scott, thanks for the nod to Canada and our wait time rules. I am in Manitoba, where we have the longest wait times in the country, which the public and the health system continually lament about.
Interestingly, one of the docs in my little rural hospital (26 rooms, 2 ER beds, 2 Observation beds) commented that he would rather work in an Emergency Department than a walk in clinic (his reference to the majority of patients in our hospital being non acute). So maybe he got the wrong job description. Even in EMS which is my area, we don’t live up to the media glorification of what we do.
Great discussion, keep ’em coming!

Thank-you Dr. Weingart for putting a voice to what goes on in my head. I was so naive entering this specialty and I do have cognitive dissonance from what I tell myself I do. I live for the sick, sick patient and find the time just flies by when in their room. I smile ( rare, rare, rare) and feel satisfaction…please don’t think I am mercenary, I just feel that this was what I signed up for. In contrast, the “prescription refill” comes in and my eyes roll so far back in my head, I see my cerebellum..You couple that with the mind numbingly stupid patient satisfaction, the suit’s “time and interval measurements” and the many checkbook algorithms we are told gives us “value”, and I am left with the persistent thought I should have opened a brewery….And, I do believe you won the debate, hands down.

Hearing this made me feel better. I always thought that this is just my problem, and these are vicious thoughts coming to my tired brain. Now I feel they are not so vicious once they are explained. I feel that I have less to nag about when I’m on shift, realizing that what I have trained for is different from what I am doing. I’ve stopped resisting and trying to be the EM doctor, when the system really needs an ER doctor. Sometimes we need someone else to explain what we already know. Thanks for doing that. 🙂